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DIPHTHERIA 

Its  Nature  and  Treatment 

BY 

C.  E.  BILLINGTON,  M.D. 

AND 

Intubation  in  Croup 


AND    OTHER 


ACUTE  AND  CHRONIC  FORMS  OF  STENOSIS 
OF   THE    LARYNX 

BY 

JOSEPH  O'DWYER,  M.D. 


NEW    YORK 

WILLIAM     WOOD     AND     COMPANY 

56  &  58  LAFAYETTE  PLACE 

1889 


Copyright,  1889. 
WILLIAM  WOOD  &  COMPANY. 


PRESS    OF 

THE    PUBLISHERS'    PRINTING   COMPANY, 

157-159    WILLIAM    STREET, 

NEW    YORK. 


PREFACE. 


I  have  been  emboldened  to  offer  the  present  work  to  the 
Profession  by  the  many  gratifying  assurances  which  I  have 
received  that  my  previous  writings,  which  appeared  in  1876 
and  at  several  subsequent  times,  have  been  of  service  to  some. 
Those  writings  consisted  mainly  in  statements  of  my  own 
clinical  observations  and  experience.  My  chief  motive  in  add- 
ing the  present  one  has  been  a  desire  to  express  my  views 
on  various  important  points  somewhat  more  fully  than  was 
possible  in  them,  and  in  connection  with  related  facts  in  the 
history,  the  etiology,  and  the  pathology  of  the  disease,  and 
recent  advances  in  its  therapeutics. 

To  have  made  this  an  exhaustive  treatise  would  have  been 
impossible,  in  view  of  the  great  variety  of  aspects  which  have 
been  assumed  by  the  disease  and  its  complications  in  occasional 
epidemics  and  individual  cases,  the  wide  diversity  of  the  views 
which  have  been  entertained  as  to  its  pathology,  and  of  agents 
and  methods  which  have  been  employed  in  its  treatment,  the 
resulting  vastness  of  the  literature  relating  to  it,  and  the 
limitations  of  the  time  and  space  at  my  disposal.  I  have, 
however,  endeavored  to  present  a  clear  and  succinct  state- 
ment of  those  facts  in  existing  knowledge  which  are  most  es- 
sential to  the  formation  of  an  intelligent  opinion  as  to  its 
nature,  and  of  those  therapeutical  principles  and  details,  the 


IV  PREFACE. 

comprehension  and  application  of  which  will,  as  I  believe,  en- 
able the  physician  to  treat  it  most  successfully. 

It  affords  me  much  pleasure  that  Dr.  O'Dwyer  has  kindly 
consented  to  treat,  in  this  connection,  of  that  very  important 
addition  made  by  him  to  our  therapeutical  resources  in  deal- 
ing- with  the  most  distressing"  and  fatal  form  of  diphtheria, — 
intubation  of  the  larynx. 

C.   E.   BlLLINGTON. 
New  York,  April  15, 


CONTEXTS. 


CHAPTER  I. 

PAGE 

Definition  and  History 1 

CHAPTER  II. 
Etiology 16 

CHAPTER   III. 
Pathology 46 

CHAPTER  IV. 
Symptoms 68 

CHAPTER  V. 

The  Primary  Nature  of  Diphtheria 96 

CHAPTER  VI. 

Secondary  Diphtheria. 104 

CHAPTER  VII. 
Diphtheritic  Paralysis 108 

CHAPTER   VIII. 
Diagnosis 121 

CHAPTER  IX. 
Prognosis 139 

CHAPTER  X. 
Prophylaxis 145 

CHAPTER  XL 
Treatment 150 

APPENDIX. 
Etiology 259 


INTUBATION  IN  CROUP 

And  other  Acute  and  Chronic  Forms  of  Stenosis  of  the  Larvnx        265 


DIPHTHERIA; 


ITS    isTATTTEE    AOT)    TREATMENT. 


CHAPTER  I. 

DEFINITION  AND  HISTORY. 


Diphtheria  is  a  specific  disease  which  occurs  sporadically, 
endemic  ally  and  epidemically,  and  is  contagious  and  infectious, 
its  essential  characteristic  being-  an  inflammation  of  mucous 
membranes,  or  of  the  surface  of  wounds  and  the  adjoining  in- 
tegument, which  tends,  by  cellular  proliferation  and  degenera- 
tion and  by  fibrinous  exudation,  to  the  formation  of  a  false 
membrane,  and  also  to  the  production  of  a  poison  which,  when 
absorbed  into  the  circulation,  causes  morbid  changes  in  the 
blood  and  in  various  organs  of  the  body. 

The  name  diphtheria  was  first  suggested  by  Bretonneau, 
who  in  his  earlier  publications  employed  the  term  diphtherite, 
derived  from  the  Greek  8i<pdspa,  a  membrane,  the  termination 
ite  (i-->jc)  signifying  inflammation,  and  the  compound  word 
thus  admirably  describing  the  "specific  phlegmasia"  wmich 
constitutes  the  local  affection;  but  in  his  fifth  memoir  he 
adopted  instead  from  Trousseau  the  name  diphtherie,  which, 
without  the  limiting  suffix,  more  fitly  designates  the  entire 
disease  with  its  train  of  local  and  constitutional  phenomena. 
The  equivalent  name,  diphtheria,  was  thence  adopted  by  Dr. 
W.  Farr,  Register  General  of  England,  and  has  since  been 
universally  emploved  by  writers  in  the  English  language. 


2  diphtheria;   its  nature  and  treatment. 

Although  this  name  and  much  of  the  more  exact  knowl- 
edge of  the  disease  which  has  accompanied  and  followed  its 
introduction  are  of  recent  origin,  there  is  abundant  evidence 
that  the  malady  itself  has  prevailed  widely  among  mankind 
since  the  most  ancient  times.  In  the  sixth  century  B.C.  or 
thereabouts,  D'havantare,  an  Indian  physician,  in  his  "  System 
of  Medicine/'  written  in  Sanskrit,  described  the  symptoms  of 
an  incurable  disease  called  "  closing  of  the  throat,"  and  "  aris- 
ing from  phlegm  combined  with  blood,"  which  could  hardly 
have  been  other  than  diphtheria.1  The  assertion,  which  has 
been  made  by  some,  that  the  disease  is  referred  to  in  the 
Hippocratic  writings,2  rests  on  very  inconclusive  evidence. 
Asclepiades,  in  the  first  century  B.C.,  is  said  to  have  performed 
laryngotomy.  Aretaeus  of  Cappadocia,  in  the  first  century 
a.d.,  gives  a  graphic  and  unmistakable  description  of  faucial 
and '  laryngeal  diphtheria  under  the  names  ulcera  ^gyptiaca 
and  ulcera  Syriaca,  which  are  significant  of  its  wide  preva- 
lence. He  says  that  "some  ulcers  on  ths  tonsils  are  mild  and 
others  are  pestilential  and  deadly."  The  latter  are  "  exten- 
sive, deep,  putrid  and  coated  with  white,  livid  or  black  concre- 
tions." He  then  describes  the  development  and  extension  of 
this  form  of  the  disease  in  the  throat  and  the  mouth  and  as  a 
phlegmon  on  the  neck,  and  its  fatal  result  in  "not  many 
days,"  and  adds,  "  But  if  this  malady  invades  the  chest  through 
the  windpipe,  it  causes  suffocation  on  the  same  day."  He  then 
vividly  depicts  the  symptoms  and  the  struggles  which  are  too 
often  witnessed  in  the  later  stages  of  a  fatal  case  of  diphthe- 
ritic croup  and  completes  the  nosological  picture  by  adding, 
"Children  up  to  the  age  of  puberty  are  chiefly  affected  by 
this  disease."3  Galen  probably  referred  to  diphtheria  when 
he  mentioned  the  expectoration  of  false  membrane  from  the 


1  Quoted  in  "Diphtheria,  its  Nature  and  Treatment,"  by  Morell 
Mackenzie,  M.D.,  p.  14. 

2  Hippocrates:  "  de  Epidemicis,"  lib.  v.  cap.  iv.,  and  "de  Dentitione." 
3Aretaeus :  "  De  Causis  et  Signis  Acutorum  Morborum,"  lib.  1.  cap.  9. 


DEFINITION    AND    HISTORY.         ■  6 

pharynx  ana  the  air-passages.1  Ccelius  Aurelianusin  the  third 
century  depicted  the  symptoms  of  diphtheritic  laryngitis  and 
also  mentioned  the  imperfect  articulation  and  the  regurgita- 
tion of  liquids  through  the  nose  in  swallowing,  which  result 
from  diphtheritic  faucial  paralysis.2  Aetius  of  Amida  in  the 
fifth  century  described  a  disease  of  children,  in  which  the 
whitish  and  grayish  faucial  appearances,  the  dysphagia,  the 
suffocation,  the  characteristic  symptoms  of  resulting  palatal 
paralysis,  sudden  death  after  apparent  recovery,  and  intoler- 
ance of  too  harsh  local  treatment  form  a  complete  clinical 
picture  of  diphtheria.3  The  probability,  from  some  passages 
in  the  historians,  that  severe  epidemics  of  this  disease  may 
have  occurred  in  antiquity,  of  which  we  have  no  record  by 
medical  writers,  is  illustrated  by  Bretonneau  (second  memoir) 
in  the  instance  that  Macrobius  in  the  year  380  a.d.  speaks, 
according  to  Julius  Modestus,  of  sacrifices  which  were  insti- 
tuted in  honor  of  a  heathen  goddess,  "ut  populus  E-omanus 
morbo  qui  Angina  dicitur,  promisso  voto,  sit  liberatus." 

For  an  interval  of  more  than  a  thousand  years,  which  con- 
stituted the  "  Dark  Ages/'  there  is  no  distinct  record  of  the 
disease,  probably  not  from  its  non-occurrence,  but  from  a  lack 
of  competent  observers.  It  is  with  good  reason  supposed  that 
some  of  the  "plagues"  of  the  Middle  Ages  may  have  been 
epidemics  of  diphtheria.  Among  these  were  the  pest  called 
"  esquinancie/'  a  form  of  angina  maligna  mentioned  in  the 
chronicle  of  St.  Denis  for  the  year  580,  and  a  destructive  "pes- 
tilentia  faucium  "  at  Rome  in  856,  and  another  in  1004  recorded 
by  Baronius,  and  a  fatal "  cynanche  "  in  the  Byzantine  empire 
in  1037  recorded  by  Cedrenus,  and  an  angina  which  carried  off 
many  children  in  England  in  1389,  referred  to  by  Short.4 

In  the  sixteenth  century  records  of  the  occurrence  of  epi- 


lf'De  Locis  Affectis,"  lib.  1.  cap.  9. 

2"De  Aeutis  Morbis,"  lib.  iii.,  cap.  2  et  cap.  iv. 

3  Petrabibl.  Serrao  viii. ,  cap.  46. 

4  Cited  by  Hirsch,  Greog.  and  Hist.  Pathol.,  vol.  iii. 


4  diphtheria;   its  nature  and  treatment. 

demies  of  diphtheria  beg-in  rapidly  to  multiply.  Among-  these 
an  epidemic  in  Holland  in  1557  was  described  by  Peter  Forest  * 
as  an  "angina  maligna  contagiosa,"  rapidly  fatal  by  strangu- 
lation, and  another  in  1564  and  1576  mentioned  by  Van  Wier2 
as  an  "  angina  maligna,"  particularly  common  among  children 
and  fatal  in  from  one  to  seven  days;  others  occurred  in  the 
Rhenish  provinces  and  in  North  Germany,  and  one  in  Naples 
and  Sicily.  An  epidemic  in  Paris  in  1576  was  described  by 
Baillou,3  who  mentioned  false  membrane  as  observed  in  an 
autopsy :  "  Pituita  lenta  contumax  quae  instar  rnembranae  cu- 
jusdam  arterige  asperse  erat  obtenta." 

In  Spain  a  great  epidemic,  or  succession  of  epidemics,  of 
angina  maligna,  there  known  under  the  popular  name  of  gar 
rotillo,  raged  from  1583  to  1618,  and  was  well  described  by  a 
number  of  medical  writers.  Beginning  in  Seville  in  the  former 
year,  it  reached  its  widest  diffusion  over  the  country  about  1610, 
and  in  1613  the  mortality  was  so  frightful  that  that  year  has 
since  borne  the  name  of  "anno  de  los  garrotillos."  Among 
the  best  descriptions  of  the  disease  were  that  of  Villa  Real,4 
who  minutely  described  false  membrane  as  seen  by  him,  not 
only  in  many  cases  during  life,  but  also  in  autopsies;  that  of 
Herrera,5  who  also  observed  diphtheritic  false  membrane  in 
autopsies,  and  described  diphtheria  of  the  skin  and  of  wounds ; 
that  of  Mercado,6  physician  to  Philip  II.  and  Philip  III.,  who 
noted  the  slight  degree  of  fever  present  in  some  very  grave 
cases,  described  diphtheritic  cervical  adenitis,  and  mentioned 
an  instance  of  a  child  communicating  the  disease  to  its  father 

'"Observat.  et  Curat.  Medic."  lib.  vi.,  observ.  ii.,  schol.  Lugd.  Bat., 
1591. 

2  Van  Wier :  Observat.  lib.  i,  sec.  3. 

^Epideiiiiorum,  lib.  ii.,  Grenev.  1762. 

4  Villa  Real :  "  De  Signis  Causis,  Essentia,  Prognostico  et  Curatione 
Morbi  Suffocantis,"  Compluti  1611. 

5 "  De  Essentia,  Causis,  Notis,  Presagio,  Curatione  et  Precautione 
Morbi  Suffocantis  Garrotillo  Hispane  Appellati,"  auctore  Doctore 
Herrera,  Matriti,  1615. 

"Consult,  med.  lib.  cons,  xiv.,  in  opp.  Frankf.  1620. 


DEFINITION   AND    HISTORY.  O 

by  biting-  his  finger;  and  of  Heredia,1  physician  to  Philip  IV., 
who  distinguished  the  two  forms  of  the  disease,  the  suffocative 
and  the  asthenic,  observed  paralysis  of  the  palate,  the  pharynx 
and  the  limbs,  believed  in  a  secondary  infection  by  the  resorp- 
tion of  morbid  products,  and  recommended  for  its  prevention 
the  early  employment  of  cauterization. 

An  epidemic  in  Portugal  in  1626  is  described  by  Bar- 
bosa.2 

In  Italy  malignant  sore  throat,  having  been  prevalent  in 
Mantua  and  Lombardy  in  1610,3  broke  out  in  the  city  of  Naples 
in  1617,  gradually  overran  the  kingdom  of  the  Two  Sicilies 
and  the  States  of  the  Church,  and  prevailed  in  various  epi- 
demics and  recurrences  in  many  parts  of  Italy  until  1650. 
Among  the  accounts  of  these  epidemics  are  that  of  Sgambatus,4 
Carnevale,5  Aetius  Cletus,6  who  vividly  described  not  only 
pseudo-membrane  in  the  fauces,  but  the  gangrenous,  the  laryn- 
geal, the  toxaamic,  the  asthenic,  and  the  nasal  forms  of  the 
disease,  and  also  the  protracted  debility  and  the  paralysis  of 
the  vocal  organs  of  those  who  recovered;  and  Severino,7  who 
described  diphtheritic  membrane  as  seen  in  an  autopsy,  and 
diphtherial  paralysis. 

In  the  eighteenth  century  angina  maligna  was  even  more 
prevalent  than  in  the  seventeenth,  occurring  in  nearly  every 
country  of  Europe  and  in  some  portions  of  America.  Many 
localities  in  Spain  and  Portugal  were  invaded  by  it  between 
the  years  1701  and  1786.  It  prevailed  in  Paris  and  in  many 
other  towns  in  France  in  1743-50;  again  in  Paris  in  1758-9  and 
in  1762.    The  first  of  these  epidemics  was  described  by  Marteau 


1 "  De  Alorbis  Acutis,"  lib.  ii.,  sec.  iii.,  cap.  5.    Lyon,  1685. 
2"  Estudios  sobre  o  garrotilho  ou  croup."  Lisbon,  1861. 
3Corradi  "Annali  delle  Epideinie  occorse  in  Italia,"  iii.  16. 
4"De  Pestilente  Fauciuni  Affectu,  Neapoli   Sceviente  Opusculum," 
auctore  Andrea  Sgambato.    Neapoli,  1620. 

5"  De  Epidemico  Strangulatorio  Affectu,"  etc.    Neapoli,  1620. 
6"  De  Morbo  Strangulatorio  opus."    Roinae,  1636. 
'•  "  De  Pedauchone  Maligna,"  etc.    Neapoli,  1643. 


6  diphtheria;   its  nature  and  treatment. 

de  Grandvilliers,1  and  by  Chomel,2  who  accurately  described 
paralysis  of  the  soft  palate,  and  a  case  of  diphtheritic  strabis- 
mus. Epidemics  occurred  in  various  portions  of  Italy  between 
1747  and  1786.  One  which  prevailed  in  Palermo  in  1747-8  was 
described  by  Ghisi,3  who  observed  laryngeal  croup  and  pharyn- 
geal angina  gangrenosa  as  each  occurred  separately,  and  when 
both  were  united  in  the  same  patient,  and  noted  the  phenom- 
ena of  diphtheritic  paralysis.  Epidemic  outbreaks  occurred 
in  Holland  between  1745  and  1770.  In  Great  Britain  an  epi- 
demic of  angina  maligna,  was  described  in  1713  by  Dr.  Patrick 
Blair,4  under  the  name  of  "the  croops"  as  "universal"  at 
Coupar  Angus.  In  1748  a  fatal  outbreak  in  London  of  scar- 
latina anginosa,  which  was  complicated  with  diphtheria,  was 
described  by  Dr.  Fothergill.5  In  1745-8  a  "morbus  strangula- 
torius,"  which  presented  the  characteristic  features  of  malig- 
nant diphtheria,  prevailed  in  Cornwall,  and  was  described  by 
Starr.6 

In  1765  appeared  the  treatise  on  croup  by  Francis  Home 
of  Scotland.7  This  work  is  very  important,  not  only  from  the 
completeness  of  its  descriptions  and  the  logical  force  of  its  de- 
ductions, but  also  from  the  fact  that  it,  for  the  first  time, 
clearly  depicts  a  form  of  pseudo-membranous  disease  which 
was  regarded  by  him  and  has  since  been  regarded  bjr  many 
others  as  distinct  from  diphtheritic  angina.  According  to 
him  croup,  or,  as  he  names  it,  "  suffocatio  stridula,"  is  a  dis- 
ease which  "  belongs  peculiarly  to  children."     It  "  has  a  local 

1 "  Dissertation  Historique  sur  l'espece  de  Mai  de  Gorge  Grangreneux 
qui  a  regne'  parmi  les  Enfants  l'annee  derniere."    Paris,  1749. 

2 "Dissert.  Hist,  sur  l'aspect  du  Mai  de  Gorge  Grangreneux,"  etc., 
Paris,  1749. 

8"  Lettere  Mediche  del  Dottore  Martino  Grhisi."    Cremona,  1749. 

4"  Observations  in  the  Practice  of  Physic,"  etc.     London,  1713. 

5 "An  Account  of  the  Sore  Throat  Attended  with  Ulcers,"  by  Dr. 
John  Fothergill.    London,  1748. 

6 "  Philosophical  Transactions,"  1750,  t.  xlvi.,  p.  435. 

1  "An  Inquiry  into  the  Nature,  Causes  and  Cure  of  Croup,"  by  Fran- 
cis Home,  M.D.    Edinburgh,  1765. 


DEFINITION   AND    HISTORY.  7 

situation,"  being-  "seldom  found  at  any  great  distance  from 
the  sea-shore/'  though  "  very  wet  and  marshy  situations  some- 
times produce  it."  Its  occurrence  is  also  favored  by  cold  and 
damp  weather,  and  recent  attacks  of  measles,  whooping-cough 
or  small-pox  predispose  to  it.  It  is  "  a  disease  of  an  inflam- 
matory nature,"  which  "  appears  to  be  confined  chiefly  to  the 
trachea,  as  the  patients  have  no  pain  in  deglutition,  and  as  the 
fauces  are  at  most  but  a  little  redder."  "  The  place  first  and 
most  particularly  affected  is  the  upper  part  of  the  trachea, 
about  an  inch  below  the  glottis."  "  The  cause  of  this  disease 
is  a  preternatural  white,  tough,  thick  membranous  crust  cov- 
ering often  for  many  inches  the  inside  of  the  trachea."  "  This 
membrane  is  not  attached  to  the  parts  below,  but  is  easily 
separated  from  them,  as  there  is  always  matter  behind  it." 
There  are  two  forms  of  the  disease,  "  the  inflammatory  and 
less  dangerous,  and  the  less  inflammatory  and  highly  danger- 
ous." This  description  is  based  on  twelve  cases,  of  which 
three  were  of  the  former  or  catarrhal  variety,  and  terminated 
in  recovery,  and  are  given  as  examples  of  those  which  are 
"common."  The  other  nine  were  fatal  ones,  and  in  all  of  these 
autopsies  were  made,  the  membrane  as  above  described  being 
found  in  every  one.  In  only  one,  which  he  regarded  as  com- 
plicated with  "  angina,"  the  throat  and  tonsils  were  inflamed 
and  "  covered  with  mucus."  There  is  no  mention  of  an  epi- 
demic character  nor  of  contagiousness  in  the  disease  described, 
but  it  is  possibly  worthy  of  note  that  two  of  the  fatal  cases 
(IV.  and  V.)  were  those  of  a  brother  and  sister,  the  former 
having  been  attacked  September  29th,  1760,  the  latter,  Octo- 
ber 5th.  The  treatment  he  advises  consists  of  blood-letting, 
blisters,  emollient  fomentations  and  cataplasms  around  the 
neck,  inhalation  of  the  steam  of  water  and  vinegar,  and  gentle 
sudorifics.  Emetics  he  had  not  found  useful.  When  the  mem- 
brane has  formed  he  recommends  bronchotomy. 

Diphtheria  again  prevailed  in  London  and  in  some  other 
localities  in  England  in  1790-1793. 


8         DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 

Epidemics  occurred  in  Germany  in  1752,  1755  and  1790.  In 
1778  Michaelis 1  in  Gottingen  wrote  in  confirmation  of  the  de- 
scriptions and  views  of  Home.  The  disease  prevailed  in  the 
Simmenthal,  Switzerland,  in  1752,  and  in  many  places  in 
Sweden  in  the  years  1755-62.  In  the  latter  country  Wilcke  in 
1757  described  pseudo-membranous  angina.2 

In  New  England  an  epidemic  occurred  in  1735,  which  was 
described  by  Dr.  "William  Douglas 3  as  originating  in  Kings- 
ton township,  about  fifty  miles  eastward  of  Boston,  and  after 
prevailing  with  great  fatality  in  the  surrounding  country,  at 
length  reaching  Boston,  where  it  was  much  milder.  The 
symptoms  of  this  malady,  which  are  fully  detailed,  are  clearly 
those  of  scarlatina,  but  in  many  instances  there  was  evidently 
a  complicating  or  secondary  diphtheria. 

Two  years  later  a  similar  epidemic  is  described  in  a  letter 
from  Rev.  J.  Dickinson,4  dated  "  Elizabeth  Town,  New  Jersey, 
February  20,  1738-*9,"  as  having  occurred  in  that  place  some 
time  previously,  a  portion  of  which  description  is  so  vivid  as 
to  be  worthy  of  quotation.  He  describes  the  disease  in  six 
forms,  the  first  being  evidently  scarlatina,  or  possibly  in  some 
cases  measles.  The  second  form  "frequently  begins  with  a 
slight  indisposition,  much  resembling  an  ordinary  cold,  with  a 
listless  habit,  a  slow  and  scarce  discernible  fever,  some  sore- 
ness of  the  throat  and  tumefaction  of  the  tonsils;  and  perhaps 
a  running  of  the  nose,  the  countenance  pale  and  the  eyes  dull 
and  heavy.     The  patient  is  not  confined,  nor  any  danger  ap- 

1 "  De  Angina  Polyposa  Membranacea."     Grottingen,  1778. 

2 "Diss.  Med.  de  Angina  Infantum."    Upsala,  1764. 

3 "The  Practical  History  of  a  New  Epidemical  Eruptive  Miliary 
Fever  with  an  Angina  Ulcusculosa  which  prevailed  in  Boston,  New 
England,  in  the  years  1735  and  1736.  Printed  and  Sold  by  Thomas 
Fleet. 

4 "  Observations  on  that  Terrible  Disease,  Vulgarly  called  the  Throat- 
Distemper,  with  Advices  as  to  the  Method  of  Cure."  In  a  Letter  to  a 
Friend.  By  J.  Dickinson,  A.M.  Boston :  Printed  and  Sold  by  S.  Knee- 
land  and  T.  Green  in  Queenstreet  over  against  the  Prison,  1740."  Jon- 
athan Dickinson  was  the  first  President  of  Princeton  College  and  the 
first  pastor  of  the  Presbyterian  church  of  Elizabeth,  N.  J. 


DEFINITION    AND    HISTUKY.  9 

prehended  for  some  days,  until  the  fever  gradually  increases, 
the  whole  throat  and  sometimes  the  roof  of  the  mouth  and 
nostrils  are  covered  with  a  cankerous  crust,  which  corrodes 
the  contiguous  parts  and  frequently  terminates  in  a  mortal 
gangrene.  When  the  lungs  are  thus  affected  the  patient  is 
first  afflicted  with  a  dry,  hollow  cough,  which  is  quickly  suc- 
ceeded with  an  extraordinary  hoarseness  and  total  loss  of  the 
voice,  with  the  most  distressing  asthmatic  symptoms  and 
difficulty  of  breathing,  under  which  the  poor  miserable  creat- 
ure struggles  until  released  by  a  perfect  suffocation  or  stop- 
page of  breath.  This  last  has  been  the  fatal  symptom  under 
which  the  most  have  sunk  that  have  died  in  these  parts.  All 
that  I  have  seen  to  get  over  this  dreadful  symptom  have '  by 
their  perpetual  cough  expectorated  incredible  quantities  of  a 
tough  whitish  slough  from  their  lungs/' 

Dr.  Cadwallader  Colden1  traces  the  progress  of  the  epi- 
demic from  Kingston  westward,  it  appearing  "  first  in  those 
places  where  the  people  of  New  England  chiefly  resorted  for 
trade,  and  in  the  places  through  which  they  travelled  "  until 
it  "spread  over  all  the  British  colonies  in  the  Continent," 
"children  and  young  people"  being  "only  subject  to  it;  "  but 
he  adds  nothing  of  importance  to  the  two  descriptions  of  the 
disease  just  quoted. 

In  1771  appeared  the  classical  treatise  of  Dr.  Samuel  Bard2 
of  New  York,  who  described  with  clearness  and  accuracy 
pharyngeal,  laryngeal  and  cutaneous  diphtheria,  occurring 
separately  and  in  the  same  patients,  from  clinical  observation 

1 "  Extract  of  Letter  from  Cadwallader  Colden,  Esq.,  to  Dr.  Fothergill 
concerning  the  Throat  Distemper,"  dated  Coldenham  in  New  York, 
1753.     Published  in  London  Observations  and  Inquiries,  vol.  i.,  p.  211. 

'2  "An  Enquiry  into  the  Nature,  Cause  and  Cure  of  the  Angina  Suffo- 
eativa  or  Sore-Throat  Distemper  as  it  is  commonly  called  by  the  In- 
habitants of  this  City  and  Colony.  By  Samuel  Bard,  M.D.,  and  Pro- 
fessor of  Medicine  in  King's  College,  New  York.  Printed  by  S.  Inslee 
and  A.  Car,  at  the  New  Printing-Offlce  in  Beaver  Street,  MDCCLXXI." 
Reprinted  in  Transactions  of  the  American  Philosophical  Society, 
Philadelphia,  1789. 


10  DIPHTHERIA;     ITS   NATURE   AND   TREATMENT. 

and  post-mortem  examination,  as  pseudo-membranous  but  not 
gangrenous  affections,  and  believed  that  these  various  forms 
of  disease,  with  those  described  by  the  Italian  writers  and  by- 
Home,  Fothergill,  Huxham  and  Douglas,  were  essentially  re- 
lated and  "arise  from  the  same  leaven."  He  also  described 
consecutive  paralysis  affecting-  deglutition,  speech  and  locomo- 
tion, and  emphasized  the  infectiousness  of  the  disease  and  the 
importance  of  isolating  the  sick. 

Although  the  masterpiece  of  Bard  has  in  recent  times  been 
appreciated  at  its  true  value,  it  does  not  seem  to  have  com- 
manded the  contemporaneous  attention  which  it  merited,  and 
the  ideas  of  Home  maintained  their  ascendancy. 

Their  influence  is  illustrated  in  a  "letter  on  the  croup" 
from  P.  Middleton,1  M.D.,  to  Mr.  Richard  Bayley,  surgeon, 
New  York,  dated  New  York,  November  30,  1780.  He  says, 
"When  I  first  came  (from  Scotland)  to  this  city  in  1752,1 
found  complaints  of  the  throat  not  infrequent,  but  most  of 
them  were  usually  considered  as  having  a  malignant  tendency 
if  not  actually  angina?  gangrenosa?,  and  in  consequence  of  this 
general  belief  antiseptics  were  the  remedies  used  in  preference 
to  all  evacuants  except  perhaps  emetics."  He  proceeds  to 
state  his  belief  that  croup  is  "  totally  distinct  from  malignant 
sore  throat/'  and  asserts  that  though  the  two  affections  may 
be  united,  he  has  never  seen  such  an  instance. 

Similar  views  appear  in  a  letter  on  the  croup  from  Professor 
Richard  Bayley2  to  William  Hunter,  M.D.,  London,  published 
about  1781.  He  quotes  with  approval  the  post-mortem  obser- 
vations of  Bard,  but  regards  angina  trachealis  as  an  "  inflam- 
matory "  affection,  and,  like  Dr.  Middleton,  has  treated  it  suc- 
cessfully, even  in  its  advanced  stages,  by  the  vigorous  employ- 
ment of  venesection,  blisters,  mercurial  evacuants  and  emetics. 

Dr.  John  Archer,3  in  a  letter  to  Benjamin  Smith  Barton, 

1  Medical  Repository,  New  York,  vol.  xiv.,  p.  347. 

2  Medical  Repository,  New  York,  vol.  xii.,  p.  331,  and  vol.  xiv.,  p.  345. 

3  Medical  Repository,  New  York,  vol.  ii.  p.  27. 


DEFINITION   AND    HISTORY.  11 

M.D.,  of  Philadelphia,  dated  Hartford  County,  Maryland, 
March  IT,  1798,  likewise  considers  croup  as  a  "topical  disease, 
confined  to  the  trachea  arteria,  and  the  several  ramifications 
thereof." 

In  France,  also,  at  this  period  most  writers  held  the  same 
views  regarding  the  distinct  nature  of  croup  and  angina  ma- 
ligna. 

Several  members  of  the  imperial  family  having  died  of  the 
former  disease,  a  prize  was  offered  by  Napoleon  I.  for  the  best 
essay  upon  it.  This  prize  was  divided  between  Jurine,  of 
Geneva,  and  Albers,  of  Bremen.  Jurine  recognized  the  fact  of 
the  frequent  concurrence  of  croup  with  angina  gangrenosa, 
and  expressed  doubt  as  to  the  actual  existence  of  gangrene  in 
the  majority  of  cases  of  the  latter  disease. 

At  length  appeared  the  writings  of  Bretonneau,  which  may 
be  said  to  have  founded  on  a  firm  and  broad  basis  the  modern 
knowledge  of  diphtheria.  Many  of  the  facts  which  he  an- 
nounced respecting  the  disease  had,  as  we  have  seen,  been 
previously  observed  and  stated  ~by  others.  It  was  his  glorious 
achievement  to  establish  them  by  incontrovertible  demonstra- 
tion and  to  present  them  in  their  true  relations.  The  principal 
writings  of  Bretonneau  *  consist  of  five  papers  or  memoirs,  the 
first  t\\  o  of  which  were  read  at  the  Academie  Royale  de  Mede- 
cine  in  1821;  the  last  was  published  in  1855.  His  studies  of  the 
disease  were  principally  made  in  three  great  epidemics,  that 
of  Tours  in  1818,  de  la  Ferriere  in  1825,  and  Chenusson  in  1826. 
The  most  distinctive  feature  of  Bretonneau's  work  was  the 
great  amount  of  necroscopic  research  which  it  comprised, 
sixty  autopsies  being  referred  to  in  the  first  epidemic  alone. 
Among  the  most  important  points  established  by  his  observa- 
tions were  the  absence  of  gangrene  in  most  cases  of  diphtheria, 

1 "  Des  inflammations  speciales  du  tissu  muqueux  et  en  particulier  de 
la  diphtherite,  ou  inflammation  pelliculaire  connue  sous  le  nom  de 
croup,  d'angine  inaligne,  d'angine  gangreneuse,  etc.,  Paris,  1826." 
"  Sur  les  ruoyens  de  prevenir  le  developpement  et  les  progres  de  la 
diphtherie,"  Archives  Gren^rales  de  Medecine,  1855. 


12        DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 

the  nature  and  the  relations  of  pseudo-membrane,  its  frequent 
continuity  and  its  essential  unity  in  the  buccal,  the  naso- 
pharyngeal and  the  laryngotracheal  regions,  the  specificity 
of  the  diphtheritic  inflammation  in  distinction  from  the  catar- 
rhal and  from  other  specific  phlegmasia?,  the  non-identity  of 
membranous  and  "spasmodic"'  croup,  and  the  true  relation  of 
sequence  and  causation  between  the  local  and  the  constitu- 
tional phenomena  of  diphtheria,  which  he  expressed  in  the 
phrases,  "  localized  primitive  diphtheria  "  and  "  the  secondary 
or  constitutional  affection." 1 

The  teachings  of  Bretonneau  were  ably  seconded  and  am- 
plified by  various  writers,  among  the  earliest  of  whom  were 
Guersant,2  Louis,3  Gendron 4  and  Mackenzie,5  the  two  latter  of 
whom  were  among  the  earliest  advocates  of  the  topical  use  of 
nitrate  of  silver. 

During  the  earlier  half  of  the  present  century  the  prev- 
alence of  diphtheria  greatly  diminished,  except  in  France 
where  numerous  epidemics  occurred  between  1810  and  1843, 
and  again  from  1846  to  1855.  In  other  European  countries 
and  on  this  continent  it  was  either  unknown  or  occurred  only 
sporadically  or  in  occasional  and  limited  epidemics.  In  1856, 
an  outbreak  having  occurred  at  Boulogne,  in  France,  which 
was  especially  fatal  among  the  resident  English,  the  disease 
was  conveyed  to  England  and  prevailed  there  in  numerous 
and  fatal  epidemics  until  1863.  At  about  the  same  time  a  new 
and  more  general  outbreak  than  had  ever  before  occurred 
began  not  only  in  Europe  and  America,  but  also  in  Asia, 
Africa,  Australia  and  Polynesia;  and  that  general  prevalence 
of  the  disease  has  since  continued,  though  often  in  a  greatly 

1  Fifth  Memoir. 

2  Dictionnaire  de  M6decine,  Articles  "Angine  Couenneuse,"  t.  ii., 
"Croup,"  t.  vi.,  and  "  Stomatite  Couenneuse,"  t.  xix. 

3"  Du  Croup  consider^  chez  l'adulte,"  Arch.  Gen.,  t.  iv.,  pp.  1  and  369. 

4"  Observations  sur  une  Angine  Couenneuse,"  Journal  Compl^men- 
taire  du  Diction,  des  Sciences  Med.,  t.  xxiii.,  p.  346. 

6 "On  the  Symptoms  and  Cure  of  Croup,"  Edin.  Med.  and  Surg. 
Journ.,  vol.  xxiii.,  p.  294. 


DEFINITION   AND    HISTORY.  13 

mitigated  form,  until  the  present  time,  so  that  in  most  of  the 
cities  of  the  world  at  the  present  day  diphtheria  contributes  a 
considerable  annual  quota  to  the  list  of  mortality. 

Under  these  circumstances  it  is  not  surprising-  that  the 
literature  of  the  disease  has  assumed  enormous  proportions, 
and  is  less  and  less  occupied  with  accounts  of  particular  epi- 
demics and  more  and  more  with  questions  relating  to  etiolog}7, 
pathology,  and  therapeutics. 

As  various  writers  will  necessarily  be  referred  to  in  the 
chapters  on  these  subjects,  but  few  additional  ones  need  now 
be  enumerated.  Deslandes,  in  1827,1  in  considering  the  ques- 
tion of  the  identity  of  pseudo-membranous  angina  and  croup, 
gave  a  minute  and  valuable  historical  review  of  the  subject  of 
epidemic  sore  throat.  His  views  on  the  question  referred  to 
accord  affirmatively  with  those  of  Bretonneau.  The  doctrine 
that  diphtheria  is  a  primarily  constitutional  affection  was 
advocated  by  Emangard,2  who  attacked  the  views  of  Breton 
neau  from  the  point  of  view  of  the  "physiological"  school, 
maintaining  that  the  disease  is  of  malarial  origin  and  of  kin- 
dred nature  to  typhus— a  "  gastro-enteric  angina."  Fuchs3 
also,  after  a  historical  review  of  the  subject,  held  that  angina 
maligna  was  a  "  typhus "  identical  with  the  pulpous  form  of 
hospital  gangrene. 

Both  of  these  questions,  namely  that  of  the  identity  or  di- 
versity of  membranous  croup  and  diphtheria  and  that  of  the 
primarily  local  or  constitutional  nature  of  diphtheria,  have 
since  been  discussed  by  many  writers  from  opposite  points  of 
view,  representing  a  diversity  of  opinion  which  continues  to 
the  present  day. 

Trousseau,4  the  friend  and  pupil  of  Bretonneau,  was  his 

1  Journal  des  Progres  des  Sc.  Med.,  t.  L,  p.  152. 

2 "  Examen  Critique  du  Traits  de  la  Diphtherie  par  M.  Bretonneau. " 
Paris,  1829. 

3 "  Historische  Untersuchungen  uber  Angina  Maligna  und  ihr  Ver- 
haltniss  zu  Scarlach  und  Croup."    Wtirzburg,  1828. 

4 "Memoir  sur  une  epid^mie  d'Angine  Couenneuse  Scarlatineuse," 


14  DIPHTHERIA;     ITS  NATURE   AND   TREATMENT. 

worthy  continuator,  and  supplemented  his  work  by  adding 
from  1829  to  1858  observations  which  were  necessary  to  the 
complete  description  of  diphtheria,  especially  in  reference  to 
its  cutaneous  form  and  its  constitutional  manifestations,  in- 
cluding" albuminuria  and  the  various  forms  of  resultant  paral- 
ysis. Trousseau  was,  moreover,  like  Bretonneau,  a  warm  ad- 
vocate of  tracheotomy,  and  devoted  much  attention  to  perfect- 
ing- its  method  and  details.  The  statement  of  Bretonneau  that 
diphtheria  is  never  accompanied  by  true  gangrene,  was  shown 
to  be  subject  to  many  exceptions  by  Trousseau  and  also  by 
Becquerel,1  Billiet  and  Barthez,2  and  Simon.3 

The  occurrence  of  albuminuria  in  connection  with  diphtheria 
was  first  discovered  in  1857  by  Dr.  W.  F.  Wade,4  of  Birming- 
ham, and  was  soon  after  independently  observed  by  Dr.  Ger- 
main See,  of  Paris.5 

Diphtheritic  conjunctivitis  was  first  elaborately  treated  of 
by  Yon  Graefe 6  in  1857.  His  publication  was  closely  followed 
by  that  of  Prichard.7 

The  first  important  publication  on  the  subject  of  diphthe- 
ritic paralysis  was  that  of  Maingault.8 

The  first  precise  description  of  the  anatomical  distinctions 
between  the  different  forms  of  inflammation  of  mucous  mem- 
branes by  Virchow  in  1847,  and  the  first  announcement  of  the 
discovery  of  a  supposed  bacterial  cause  of  diphtheria  by  Lay- 
Arch.  Gen.,  t.  xxi.,  p.  541 ;  "  De  la  Diphtherite  Cutanee,"  ibid.,  t.  xxiii.,  p. 
383;  "  Lecons  Cliniques  sur  les  Angines,"  Gaz.  des  H6p.,  Nos.  86,  89,  100, 
104,  109,  115,  119,  etc. 

1 "  Relation  d'une  Epidemie  d' Affections  Pseudo-rnembraneuses  et 
Gangreneuses  qui  a  regne  a  l'Hopital  des  Enfants,"  Gaz.  Med.,  Nos.  43, 
44,  45,  46. 

2 "Maladies  des  Enfants,"  t.  i.,  pp.  285,  316. 

3  Considerations  sur  l'Angine  Gangr6neuse  et  de  son  traitement," 
Bull,  de  Therap.,  t.  xxiv.,  p.  401. 

4  Midland  Quarterly  Journal  of  the  Medical  Sciences,  April,  1858. 

5  Union  M6dicale,  1858,  p.  497. 
6Archiv.  f.  Ophthal.,  b.  1,  s.  168. 

1  British  Med.  Journ.,  1857,  p.  981. 
8  These  de  Paris,  1854. 


DEFINITION    AND    HISTORY.  15 

cock  in  1858,  and  many  important  subsequent  pathological 
and  etiological  investigations  by  others,  will  be  more  appro- 
priately referred  to  elsewhere  in  this  work. 

In  treatment,  hydrochloric  acid,  alum,  and  later  nitrate  of 
silver,  were  locally  employed  by  Bretonneau,  and  in  some  cases 
mercury  internally.  Tonics  were  advocated  by  Becquerel *  in 
1813;  alkaline  treatment  by  Baron2  in  1851;  chlorate  of  po- 
tassa  by  A.  Smith3  in  1855;  iodine  by  Lecointe,4  and  bromine 
by  Ozanam  5  in  1856;  muriated  tincture  of  iron  internally  by 
Heslop  in  1858  ;6  iron  and  chlorate  of  potassa  by  Kingsford;7 
sulphur  by  Duche 8  in  the  same  year,  and  turpentine  by  Perry 9 
in  1859. 

A  method  of  intubation  of  the  larynx  having  been  devised 
and  warmly  advocated  by  Bouchut,  a  report  on  the  subject 
was  presented  to  the  Academie  de  Medecine  by  Trousseau  in 
1858,  so  unfavorable  that  the  procedure  was  condemned  by 
the  general  verdict  of  professional  opinion,  was  abandoned  by 
its  author,  and  fell  into  such  oblivion  that  when  Dr.  Joseph 
O'Dwyer,  of  New  York,  a  quarter  of  a  century  later,  invented 
and  perfected  the  method  of  intubation  which  has  rapidly  won 
acceptance  among  the  great  therapeutical  improvements  of 
the  age,  he  did  so  in  ignorance  of  the  fact  that  his  idea  had 
been  anticipated. 

1  Op.  cit. 

2  Gazette  He'd.,  1851,  p.  524. 

3  Dublin  Hosp.  Gazette,  vol.  ii.,  p.  149. 

4  Bulletin  de  Therap.,  t.  i.,  p.  70. 

5Coinptes  Rendus  de  FAead.  des  Sci.,  t.  xlii.,  p.  102,  and  Hon.  des 
Hop.,  p.  551. 

6  Med.  Times  and  Gazette,  vol.  xxxvii.,  p.  552. 

'  Lancet,  1858,  p.  484. 

8Gaz.  des  Hop.,  Nos.  125  and  133. 

9  Med.  Times  and  Gaz.,  vol.  xxxix.,  p.  245. 


CHAPTER  II. 


ETIOLOGY. 

The  causes  of  diphtheria  are  not  fully  known.  The  knowl- 
edge which  we  have  respecting"  them  is  derived  from  the  ob- 
servation of  the  circumstances  under  which  the  disease 
naturally  occurs,  the  results  of  experiments  for  its  artificial 
production,  and  certain  facts  in  its  pathology. 

Among  the  circumstances  which  ordinarily  influence  the 
occurrence  of  diphtheria,  one  of  the  most  noteworthy  is  that 
of  age.  While  no  period  of  life  is  absolutely  exempt  from  its 
attacks,  it  is  in  the  great  majority  of  cases  a  disease  of  child- 
hood. Among  nearly  70,000  fatal  cases  comprised  in  the  re- 
turns of  the  Registrar  General  of  England,  and  analyzed  by 
Dr.  Tbursfield,1  the  numbers  per  thousand  of  the  different 
ages  were  as  follows: — 


Under  1  year,    . 

90 

From    1  to    5  years, 

450 

5  "   10      "      . 

260 

"       10  "   15       "      . 

90 

"       15  "  25      "      . 

50 

"       25  "  45      "      . 

35 

45  years  and  upwards, 

25 

The  following  table,  compiled  from  the  records  of  the  Board 
of  Health,  shows  the  ages  in  14,688  fatal  cases  of  diphtheria 
which  occurred  in  this  city  during  the  ten  years,  1873-1882. 
It  will  be  seen  that  over  eight  per  cent,  of  all  were  under  one 
year,  over  seventy-three  per  cent,  of  all  under  five  years,  and 
over  ninety-five  per  cent,  of  all,  under  ten  years. 

1  London  Lancet,  August  3,  1878. 


ETIOLOGY. 


17 


Under  1  year  of  age,    . 

Over      "       "        "      and  under  5, 

Total  under  5, 
Over  5  years  and  under  10, 

Total  under  10, 
Over  10  years  and  under  15, 


1,214 

9,622      • 

10,836 

3,212 

14,048 

311 

87 

53 

37 

34 

28 

25 

16 

12 

12 

8 

3 

6 

6 

0 

2 

14,688 

In  some  local  outbreaks  of  diphtheria,  however,  of  excep- 
tional malignancy,  the  proportion  of  adults  affected  has  been 
much  g'reater. 

The  reason  of  this  comparative  defencelessness  of  children 
against  the  invasion  of  diphtheria  is  doubtless  mainly  the 
softness  and  delicacy  of  their  mucous  membranes,  which  are 
consequently  especially  susceptible  to  irritating-  influences, 
penetrable  by  morbific  poisons,  and  liable  to  inflammatory 
affections  in  general. 

Diphtheria  occurs  by  marked  preference  in  connection  with 
various  pre-existing  diseases,  especially  those  which  produce 
inflammation,  erosion  or  ulceration  of  the  mucous  membranes 
of  the  outer  air -passages. 


15 

n 

it 

a 

20, 

20 

a 

tt 

it 

25, 

25 

a 

ti 

ti 

30, 

30 

tt 

it 

ti 

35, 

35 

tt 

n 

it 

40, 

40 

n 

it 

n 

45, 

45 

tt 

tt 

tt 

50, 

50 

n 

tt 

tt 

55, 

55 

n 

a 

tt 

60, 

60 

ti 

tt 

a 

65, 

65 

n 

tt 

tt 

70, 

70 

»( 

a 

it 

75, 

75 

ti 

tt 

it 

SO, 

80 

it 

tt 

tt 

85, 

85 

a 

ti 

it 

90, 

Total 

. 

18  diphtheria;   its  nature  and  treatment. 

For  similar  reasons  the  invasion  of  the  skin  by  diphtheritic 
inflammation  is  rendered  practicable  by  the  removal  of  the 
epidermis  by  wounds,  blisters,  etc. 

Diphtheria  occurs  by  preference  in  some  persons  through 
individual  or  family  predisposition.  Some  instances  of  great 
mortality  in  families  which  have  been  cited  by  authors  in  sup- 
port of  this  statement  were  probably  merely  illustrations  of 
the  action  of  intense  endemic  influences,  but  I  have  known  in- 
dividuals and  families  of  children  to  suffer  from  repeated 
attacks  of  the  disease  in  the  apparent  absence  of  such  influ- 
ences, in  several  successive  places  of  residence,  and  when 
others  living  in  exactly  the  same  conditions  were  exempt. 

One  attack  of  diphtheria  affords  a  temporary  immunity 
from  subsequent  ones;  but  this  is  usually,  at  least,  of  com- 
paratively short  duration.  Second  attacks  of  diphtheria  after 
an  interval  of  a  year  or  more  are  not  uncommon.  The  sever- 
ity of  recurrences  of  the  disease  does  not  seem  to  differ  in  any 
way  from  that  of  primary  attacks. 

Diphtheria  occurs  under  the  most  Avidely  varying  condi- 
tions of  climate,  temperature  and  season,  being  dependent 
upon  none;  but  its  occurrence  is  nevertheless  favored  by  cold 
and  dampness. 

In  support  of  the  former  assertion  it  may  be  stated  that 
diphtheria  prevails  in  tropical  countries,  such  as  Tunis,  Algiers, 
Egypt  and  the  East  Indies,  as  well  as  in  Iceland  and  Labra- 
dor; during  periods  of  drought  as  well  as  of  humidity;  in 
summer  as  well  as  in  winter. 

The  other  assertion,  viz.,  that  the  occurrence  of  diphtheria 
is  as  a  general  rule  favored  by  cold  and  by  humidity,  is  proved 
\)j  the  fact  that  it  is  more  prevalent  in  those  regions  and  at 
those  seasons  of  the  year  in  which  those  conditions  are  in  the 
ascendant.  In  reference  to  its  occurrence  in  different  climates, 
Hirsch  says,1  "  Its  predominance  in  the  temperate  and  cold 
zones  compared   with  its  rarity  in  the  equatorial  and  sub- 

1  Op.  eit.  p.  100. 


ETIOLOGY 


19 


tropical  regions  is  great  enough  to  be  significant,  even  if  we 
assume  that  those  differences  are  only  in  part  real  and  in  part 
to  he  accounted  for  by  the  defective  data  from  countries  of 
the  latter  class."' 

With  reference  to  seasons  of  the  year  he  states,  "  In  124 
epidemics  of  which  we  have  exact  data  in  regard  to  their  dura- 
tion, all  of  them  being  closely  circumscribed  in  place  and  of 
no  more  than  a  few  months'  continuance,  the  outbreaks 
reached  their  height  as  follows : 

32  in  the  spring. 
21      "       summer. 
30      "       autumn. 
38      "       winter." 

Of  18,688  fatal  cases  which  occurred  in  this  city  in  the 
thirteen  years  from  January  1,  1871,  to  December  31,  1886, 
according  to  the  records  of  the  Board  of  Health,  10,769  oc- 
curred in  the  half  years  beginning  with  October,  and  7,919  in 
those  beginning  with  April.  The  distribution  by  months  is 
shown  in  the  folio winer  table : 


Years 

Jan. 

Feb. 

M'ch. 

April. 

May. 

June. 

July 

Aug. 

Sept. 

Oct. 

Nov. 
251 

Dec. 

Yearly 

Totals. 

1874 

140 

97 

Ill 

115 

102 

99 

109 

103 

108 

201 

229 

1,665 

1875 

232 

196 

180 

189 

165 

195 

167 

147 

175 

206 

210 

267 

2,329 

1876 

274 

242 

209 

158 

186 

130 

81 

79 

68 

103 

102 

118 

1,750 

1877 

72 

70 

84 

79 

67 

50 

56 

53 

85 

111 

116 

108 

951 

1878 

132 

94 

105 

90 

81 

72 

50 

47 

55 

75 

101 

105 

1,007 

1879 

97 

69 

58 

36 

46 

46 

32 

39 

30 

71 

76 

71 

671 

1880 

72 

77 

65 

81 

76 

61 

89 

97 

125 

199 

234 

214 

1,390 

1881 

212 

160 

180 

164 

190 

209 

197 

173 

173 

203 

178 

210 

2,249 

1882 

218 

169 

181 

154 

156 

133 

95 

78 

63 

88 

97 

93 

1,525 

1883 

104 

87 

88 

92 

92 

82 

66 

73 

62 

82 

81 

100 

1,009 

1884 

79 

82 

73 

77 

83 

92 

70 

62 

55 

127 

139 

151 

1,090 

1885 

108 

121 

121 

115 

102 

115 

101 

71 

87 

87 

122j  175 

1,325 

1886 

155 

149 

134 

124 

142 

130 

133 

1,246 

104 

85 

165 

288  218 

1,727 

M'fchly 

Totals. 

1,895 

1,613 

1,589 

1,474 

1,488 

1,414 

1,126 

1,171 

1,618 

1,9952,059 

18,688 

Gold  and  dampness  undoubtedly  favor  the  occurrence  of 
diphtheria  mainly  as  predisposing  causes,  by  their  tendency 
to  excite  catarrhal  affections,  the  relation  of  which  to  diph- 
theria has  already  been  referred  to. 


20  diphtheria;   its  nature  and  treatment. 

A  relation  of  cause  and  effect  between  conditions  of  soil  and 
situation  and  the  occurrence  of  diphtheria  is  asserted  by  some 
authorities  and  denied  by  others.  Hirsch 1  presents  an  accu- 
mulation of  testimony  from  observers  in  different  countries  to 
the  effect  that  the  development  and  epidemic  diffusion  of  the 
disease  are  absolutely  independent  of  such  conditions,  the  evi- 
dence showing-  that  high  and  low,  dry  and  damp  situations 
and  all  geological  formations  have  been  equally  the  seat  of  its 
prevalence,  and  that  the  instances  in  which  it  has  preferred 
low,  damp,  and  ill-drained  locations  are  fully  offset  by  others 
in  which  it  has  apparently  made  the  opposite  choice. 

The  full  acceptance  of  these  facts  is,  nevertheless,  not  in- 
consistent with  the  view  that  local  dampness  does  favor  the 
occurrence  of  diphtheria. 

Dr.  1ST.  M.  Thursfield,  whose  careful  attention  to  this  sub- 
ject, and  exceptional  opportunities  for  observation  in  his  ca- 
pacity as  Health  Officer  of  a  district  comprising  a  large  urban 
and  rural  population,  entitle  his  views  to  the  most  respectful 
consideration,  says : 2 

"  While  I  believe  that  no  very  close  connection  can  be 
traced  between  the  incidence  of  diphtheria  and  what  are 
broadly  known  as  geological  formations,  there  is  the  closest 
connection  between  certain  conditions  of  subsoil  and  situation 
of  the  house,  and  the  disease.  Whatever  promotes  dampness 
of  habitation,  the  result  is  the  same. 

"  M.  Trousseau  appears  to  have  formed  his  opinion  that  the 
disease  had  no  connection  with  local  surroundings,  from  the 
fact  that  he  had  seen  it  raging  equally  on  low  undrained  local- 
ities and  on  breezy  heights,  I  have  been  called  upon  on  sev- 
eral occasions  to  investigate  outbreaks  of  diphtheria  on  ele- 
vated open  localities,  and  have  invariably  found  the  same 
condition  of  dampness  of  habitation,  caused  by  faulty  con- 
struction of  the  houses  in  localities  where  there  was  a  stagna- 

1  Op.  eit.  p.  104. 

■  London  Lancet,  August  10,  1878. 


ETIOLOGY.  21 

tion  of  water,  either  from  a  flat  table-land  with  an  impervious 
sub-soil,  or,  more  frequently,  from  the  locality  being-  the  divi- 
sion of  a  water-shed,  which  is  always  a  cause  of  stag-nation  of 
water." 

Diphtheria,  as  a  general  rule,  prevails  with  greater  fatality 
in  rural  regions  than  in  cities.  This  fact,  which  has  been  noted 
in  the  history  of  many  epidemics,  is  illustrated  by  Dr.  Thurs- 
field *  in  tables  which  show  a  much  larger  percentage  of  deaths 
from  diphtheria  to  population  in  ten  rural  counties  than  in  ten 
principal  cities  of  England  throughout  a  series  of  years.  Dr. 
Thursfield  remarks,  "  Whatever  conditions  seem  to  favor  fun- 
goid growth  would  seem  to  favor  the  incidence  and  persistence 
of  diphtheria,  and  the  explanation  of  the  comparative  freedom 
of  towns  from  the  disease  may  be  the  presence  of  something 
in  their  atmosphere  inimical  to  such  growth." 

May  not  a  partial  explanation,  however,  be  found  in  the 
fact  that  the  inhabitants  of  cities  are,  upon  the  whole,  better 
sheltered  from  the  inclemencies  of  the  weather  and  less  ex- 
posed to  "  dampness  of  habitation  "  than  those  of  the  country? 

Diphtheria  may  occur  independently  of  insanitary  condi- 
tions. Indeed  in  some  epidemics  it  has  seemed  to  find  most  of 
its  victims  in  circumstances  where  the  action  of  such  causes 
could  least  be  suspected.  There  is,  nevertheless,  abundant 
evidence  that  its  occurrence  is  favored  by  them.  The  instances 
of  its  outbreak  and  prevalence  in  the  country  in  direct  connec- 
tion with  such  sources  of  infection  as  damp  and  filthy  cellars, 
stagnant  pools  reeking  with  the  products  of  the  decomposition 
of  animal  and  vegetable  substances,  foul  privies,  wells  con- 
taminated with  excrementitious  matter,  etc.,  and,  in  cities, 
with  bad  sewerage  and  defective  plumbing  and  ventilation, 
and  the  combined  results  of  poverty,  filth  and  overcrowding 
of  habitations,  are  too  numerous  and  striking  to  be  rationally 
regarded  as  mere  coincidences. 

As  out-door  visiting  plrysician  to  the  Demilt  Dispensary  in 

1  Loc.  eit. 


22  DIPHTHERIA;    ITS   NATURE    AND   TREATMENT. 

the  twenty-first  ward  of  this  city  through  a  number  of  years, 
I  have  had  many  opportunities  of  observing-  the  relation  of 
occurrences  of  diphtheria  to  this  class  of  causes,  and  was  long 
ago  impressed  with  its  tendency  to  occur  and  recur  in  certain 
tenement-houses  where  some  of  these  conditions  were  most 
marked — such  especially  as  foul  and  ill-drained  cellars,  neg- 
lected and  sometimes  overflowing  cess-pools,  and  bad  plumb- 
ing, with  untrapped  sinks  and  no  air-shafts.  The  relation  of 
cause  to  effect  in  these  instances  has  been  demonstrated  by 
the  fact  that  in  some  of  these  buildings,  which  had  come  to  be 
looked  upon  by  me  and  by  my  assistants  as  diphtheria  nests, 
there  has  been  no  recurrence  of  the  disease  for  quite  a  number 
of  years  since  the  evils  referred  to  were  removed  through  the 
efforts  of  the  Board  of  Health.  It  is  probable,  moreover,  that 
it  is,  in  some  degree,  at  least,  a  result  of  the  removal  of  these 
foci  of  the  disease  that  the  mortality  from  diphtheria  in  this 
district,  which  was  in  1875  in  proportion  to  population  among 
the  greatest  in  the  city,  has  for  quite  a  number  of  years  been 
among  the  least. 

In  estimating  the  validity  of  the  argument  which  has  been 
urged  against  this  view,  from  the  fact,  already  referred  to, 
that  in  many  epidemics  diphtheria  has  been  observed  to  prevail 
among  all  classes  indifferently,  or  even  in  some  instances  es- 
pecially among  the  classes  whose  hygienic  surroundings  were 
the  best,  it  may  be  remarked  that  insanitary  conditions  are 
only  one  among  many  causes  of  diphtheria,  and  are  certainly 
not  essential  to  its  occurrence;  that  they  constitute  the  most 
potent  factors  in  its  endemic  prevalence,  but  that  when  it  is 
epidemic  other  causes,  more  direct  and  potent  and  yet  to  be 
considered,  are  often  the  efficient  ones;  and  again,  it  is  a  seri- 
ous and  dangerous  error  to  assume  that  insanitary  conditions 
are  found  only  in  the  abodes  of  the  poor.  Unfortunately  the 
application  of  sanitary  science  to  the  construction  of  dwellings 
has  not  yet  attained  such  perfection,  nor  is  its  assistance  so 
generally  and  so  intelligently  invoked  even  in  the  abodes  of  the 


ETIOLOGY.  23 

wealthy,  that  any  absolute  line  of  demarcation  can  be  drawn 
between  them  and  the  dwelling's  of  the  poor,  either  in  city  or 
countiw,  in  respect  to  their  liability  to  or  exemption  from  the 
causes  of  zymotic  disease.  In  some  instances  the  elaborate 
and  luxurious  appliances  of  modern  plumbing  have  seemed  to 
multiply,  rather  than  to  obviate,  the  insidious  dangers  from 
noxious  miasms.  While,  as  I  have  already  stated,  I  have  seen 
many  cases  of  diphtheria,  evidently  resulting  from  insanitary 
conditions  in  the  abodes  of  the  poor,  I  have  also  seen  equally 
striking  instances  of  this  connection  in  the  homes  of  the  well- 
to-do  and  in  the  mansions  of  the  rich. 

Insanitary  conditions  may  favor  the  occurrence  of  diphthe- 
ria in  two  ways :  by  producing  diseases  which  predispose  to 
the  reception  of  the  special  poison  which  causes  diphtheria, 
and  by  the  endemic  perpetuation  and  reproduction  of  that 
poison,  or  possibly  by  its  generation  de  novo. 

Diphtheria,  or  a  disease  which  closely  resembles  it  etiolog- 
ically  and  pathologically,  occurs  in  various  kinds  of  animals, 
poultry  and  birds,  and  seems  to  be  intercommunicable  between 
them  and  man. 

Facts  confirming  this  statement  have  been  published  in 
great  numbers  by  Mcati,1  Friedberger,2  Wood  and  Formacl,3 
Turner,4  Delthil,5  Paulinis 6  and  many  others.  The  following- 
instance  was  published  by  Gerhardt : 7 

"  In  the  village  of  Messelhausen,  near  Landa  in  Baden,  a 
chicken-farm  had  been  started  into  which  2,600  chickens  had 
been  brought  from  the  country  near  Verona,  Italy.  A  few 
of  these  had  diphtheria,  and  within  the  'first  six  weeks  600  of 
them  died  of  the  disease,  and,  later  on,  800  more.     The  follow- 

^'Compt.  rend."  1879,  torn.  88,  No.  6. 

2Zeitschr.  f.  Thierniedecin  und  vergl.  Pathol.,  1879,  v.  161. 

3  National  Board  of  Health  Bulletin,  1882;  Supplement  No.  7. 

4  Report  to  the  Local  Government  Board  of  London,  1887. 

5  Journ.  de  MeU,  Feb.  19,  1888. 

6  Bull.  M<5d.,  Jan.  22,  1888. 

7  Verhandlung  d.  Cong,  f .  innere  Medicin.     Wiesbaden,  1883. 


24  DIPHTHERIA;     ITS   NATURE   AND   TREATMENT. 

ing  summer  1000  chickens  were  hatched  from  eggs  laid  by 
these  hens,  and  all  of  these  died  of  diphtheria  within  the  first 
six  weeks.  Five  cats  succumbed  to  the  same  disease  at  this 
farm,  and  a  parrot  also  took  the  disease,  but  was  saved.  In 
November,  1881,  an  Italian  rooster,  about  to  be  touched  up  with 
carbolic  acid,  bit  one  of  the  attendants  in  the  left  hand  and 
foot.  The  man  was  taken  sick  with  high  fever  and  both  wounds 
were  covered  with  diphtheritic  membranes.  The  wounds 
healed  very  slowly,  the  disease  lasting  three  weeks.  Two-thirds 
of  the  farm  hands  became  affected  with  diphtheria,  and  at  the 
same  time  not  a  case  occurred  in  the  neighboring  village." 

Paulinis  relates  that  on  an  island  in  the  Greek  Archipelago 
on  which  diphtheria  had  been  previously  unknown,  an  epidemic 
among  its  population  resulted  from  taking  thither  turkeys 
affected  with  the  disease.  The  contagion  seemed  to  be  trans- 
mitted through  the  atmosphere.  The  affection  in  the  turkeys 
resembled  in  all  its  features  the  human  disease.  One  of  them 
which  recovered  was  affected  with  paralysis  and  was  unable 
to  walk. 

Diphtheria  occurs  as  the  result  of  contagion  and  infection. 
This  is  abundantly  demonstrated.  Volumes  might  be  filled 
with  the  recorded  facts  which  illustrate  it,  such  as  the  first 
introduction  of  the  disease  into  a  family  or  a  school  or  a  neigh- 
borhood by  the  arrival  of  a  person  suffering  from  it,  and  its 
subsequent  dissemination  by  communication  from  one  to  an- 
other throughout  the  community,  or  its  introduction  into  one 
country  from  another  in  the  same  manner,  and  its  subsequent 
epidemic  diffusion  through  that  country  along  lines  of  travel 
and  from  one  centre  of  infection  to  another.  Such  instances 
are  far  too  numerous  and  precise  to  admit  of  explanation 
merely  by  endemic  or  epidemic  influences.  Nor  is  their  force 
in  the  least  weakened  by  the  fact  that  many  cases  and  epi- 
demics have  occurred  which  could  not  be  thus  accounted  for. 
Diphtheria  is  contagious,  though  all  cases  of  diphtheria  are 
not  due  to  contagion. 


ETIOLOGY.  25 

Diphtheria  is  contagious  in  a  less  degree  than  scarlatina  or 
measles  or  small-pox  or  whooping-cough;  it  is  less  infectious 
than  scarlatina  or  variola  or  typhoid  fever;  nevertheless  in 
many  instances  it  manifests  both  these  qualities  in  an  extreme 
degree. 

Diphtheria  is  communicated  in  a  variety  of  ways.  The 
first  of  these  is  by  direct  contact  or  the  deposition  of  diphthe- 
ritic matter  on  the  mucous  membrane  or  upon  wounds  in  the 
skin. 

Examples  of  this  mode  of  transmission  are  furnished  by 
numerous  well-known  instances  in  which  physicians  have  con- 
tracted the  disease  by  sucking  out  tracheotomy  tubes,  or  by 
receiving  the  secretions  of  the  patient  in  the  mouth  or  nares; 
also  by  such  instances  as  that  related  by  M.  See,1  in  which  a 
woman  who  wet-nursed  a  child  affected  with  diphtheria,  com- 
municated labial  diphtheria  to  her  own  child,  which  she  also 
nursed,  and  received  the  same  affection  from  the  latter  by  fre- 
cpientty  kissing  it. 

The  demonstration  afforded  by  the  instances  referred  to  is 
not  at  all  weakened  by  the  fact  that  many  other  physicians 
have  sucked  out  tracheotomy  tubes  and  have  received  diph- 
theritic secretions  in  their  mouths  and  nares,  or  that  other 
mothers  have  suckled  and  kissed  infants  affected  with  diph- 
theria, or  that  M.  Peter 2  and  others  have  painted  their  own 
fauces  with  solutions  of  false  membrane  without  diphtheria 
resulting.  The  power  of  resistance  of  the  healthy  mucous 
membranes,  especially  in  adults,  to  diphtheritic  infection,  is, 
undoubtedly,  very  great,  and  the  infective  power  of  diphthe- 
ritic material  from  different  sources,  as  will  be  shown  further 
on,  varies  very  much.  Under  these  circumstances  a  limited 
number  of  positive  examples  of  the  communication  of  diph- 
theria by  direct  contact,  among  many  negative  ones,  is  all 
the  proof  of  its  occurrence  that  could  rationally  be  demanded. 

'Bulletin  de  la  Soc.  Med.  des  Hop.,  t.  iv.,  p.  378. 
2  Trousseau,  Op.  cit.,  vol.  i. 


26        DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 

Diphtheria  may  be  communicated  by  inoculation.  Indeed 
this  is  implied  in  the  fact  of  its  communicability  by  direct 
contact,  since  in  that  mode  of  transmission  penetration  of  the 
epithelium  by  the  infecting-  matter  is  evidently  an  essential 
condition. 

The  communicability  of  diphtheria  by  inoculation  is  illus- 
trated in  such  instances  as  that  related  by  Dr.  Paterson,1  of 
the  disease  being-  communicated  to  a  wound  on  a  finger  which 
was  thrust  down  the  throat  of  a  child  who  was  suffering  from 
it.  In  other  instances  inoculation  has  been  effected  by  the 
biting  of  the  finger  by  the  child. 

I  witnessed  not  long  since  an  instance  of  auto-inoculation 
by  transplantation.  A  lady  whom  I  saw  in  consultation  with 
Dr.  C  L.  Lang  of  this  city  had  labial  diphtheria.  She  was 
also  suffering  from  eczematous  spots  on  her  lower  limbs  which 
annoyed  her  by  itching  and  burning.  To  allay  this  discomfort 
she  placed  upon  one  of  them,  which  was  particularly  accessi- 
ble and  troublesome,  a  bit  of  blotting-paper  moistened  with 
her  saliva.  In  a  day  or  two  this  patch  became  diphtheritic 
and  continued  so  for  some  days,  but  none  of  the  neighboring 
patches  was  similarly  affected. 

That  the  communication  of  diphtheria  by  inoculation  is  at- 
tended with  difficulty  and  uncertainty,  is  shown  by  the  fact 
that  Trousseau,  Peter  and  Duchamp  scarified  their  own  fauces 
with  scalpels  charged  with  diphtheritic  matter  without  result. 
Experiments  in  the  inoculation  of  animals  with  diphtheritic 
matter  have  been  attended  with  very  varying  results.  These 
have  been  negative  in  many  instances,  as  in  the  attempts  of 
Bretonneau,  Reynal,  Harley  and  others.  Trendelenberg,2  in 
sixty-eight  operations  in  which  he  introduced  diphtheritic 
pseudo-membrane  into  the  trachea  of  rabbits  and  pigeons, 
produced  tracheal  diphtheria  in  eleven,  most  of  which  died  of 
croupal  asphyxia.     With  the  membrane  obtained  from  these 

1  Med.  Times  and  Gazette,  1866. 

2  Arch,  fur  Klin.  Chir.,  t.  x.,  1869. 


ETIOLOGY.  27 

victims  he  performed  a  second  series  of  experiments  with  sim- 
ilar results.  Oertel,1  in  twelve  similar  experiments  upon  rab- 
bits,  produced  tracheal  diphtheria  in  eight,  five  of  which  died 
by  asphyxia,  and  three  from  toxaemia,  the  autopsies  showing" 
capillary  hemorrhages  in  various  organs,  and  marked  renal 
congestion.  With  the  membrane  obtained  from  these  rabbits 
he  produced  similar  results  in  a  second  series  of  operations, 
and  repeated  them  in  a  third.  Drs.  H.  C.  Wood  and  Henry 
F.  Formad 2  performed  intra-tracheal  inoculation  upon  rabbits 
with  like  results  in  a  small  proportion  of  instances. 

Hueter  and  Tommasi  and  Oertel  introduced  diphtheritic 
matter  into  the  muscles  of  rabbits.  The  result 3  was  a  diph- 
theritic layer  on  the  edges  of  the  wounds,  hemorrhagic  inflam- 
mation of  the  muscles  and  a  general  disease  which  proved  fatal 
after  one  or  two  days.  ISTassilofT  and  Eberth,4  by  inoculating 
the  cornea,  produced  diphtheritic  keratitis  which  was  accom- 
panied with  a  general  affection  which  proved  fat'1 1  on  the  fourth 
or  fifth  day.  The  evidence  that  the  affection  induced  in  these 
instances  was  true  diphtheria  has  been  regarded  as  inconclusive 
by  many.  Drs.  Curtis  and  Satterthwaite 5  repeated  these  opera- 
tions. In  those  made  upon  the  cornea  by  them  the  result  was 
negative.  Of  thirty-eight  rabbits  inoculated  by  them  with 
diphtheritic  matter  in  the  muscles  or  by  subcutaneous  injection 
twenty-one  died  after  periods  varying  from  thirty  hours  to 
thirty-eight  days.  In  these  cases  the  authors  "failed  to  see 
anything  specifically  resembling  diphtheria  as  it  occurs  in  the 
human  subject.  The  whole  story  seemed  to  be  one  of  local 
irritant  poisoning  which  always  tended  toward  the  production 
of  an  abscess  at  the  site  of  the  inoculation,  with  greater  or  less 
concomitant  hyperemia,  ecchymoses  and  serous  infiltration  of 

^eutsch.  Arch,  fur  Klin.  Med.,  1871. 

2  National  Board  of  Health  Bulletin,  1882;  Supplement  No.  17. 
3Ziemssen's  Cyclopaedia,  vol.  i. 
4  Correspondenzblatt,  1872. 

5 "Report  of  Investigations  into  the  Pathogeny  of  Diphtheria,"  by 
Edward  M.  Curtis  and  Thomas  E.  Satterthwaite.    New  York,  1877. 


28  diphtheria;   its  nature  axd  treatment. 

neighboring"  tissues  according  to  the  degree  of  virulence  of  the 
inoculated  poison." 

Drs.  Wood  and  Formad,1  on  the  other  hand,  in  a  small  pro- 
portion of  their  subcutaneous  and  intra -muscular  inoculations 
of  rabbits  with  diphtheritic  matter,  produced  a  rapidly  fatal 
local  and  general  affection,  which  strikingly  resembled  diph- 
theria, and  which  they  regarded  as  probably  essentially  iden- 
tical with  it. 

In  the  recorded  experiments  for  the  communication  of 
diphtheria  to  the  lower  animals  by  inoculation  it  is  to  be  ob- 
served that  the  operation  is  attended  with  great  uncertainty, 
succeeding  in  only  a  small  proportion  of  all  cases;  that  it  has 
usually  failed  when  attempted  in  the  mucous  membrane  of 
the  mouth  and  fauces,  but  has  much  more  often  succeeded  in 
the  trachea. 

Diphtheria  may  be  communicated  from  one  person  to  another 
through  the  circumambient  air.  This  is  undoubtedly  its  most 
usual  mode  of  communication,  as  has  been  illustrated  in  the 
numerous  instances  in  which  the  disease  has  been  contracted 
by  persons  entering  rooms  or  houses  in  which  were  patients 
suffering  from  it,  or  has  been  brought  hy  those  affected  with  it 
to  persons  or  families  previously  exempt  from  it.  The  distance 
to  which  the  disease  can  be  thus  conveyed  by  the  atmosphere 
is  ordinarily  very  small,  though  in  some  epidemics  it  has 
seemed  to  be  wafted  by  the  winds  to  considerable  distances. 

The  contagion  from  patients  affected  with  diphtheria 
seems  to  accumulate  in  their  rooms,  to  adhere  to  walls  and 
furniture,  and  often  to  linger  for  a  considerable  time  after 
their  recovery,  as  has  been  shown  by  numerous  instances  in 
which  persons  have  taken  diphtheria  in  rooms  in  which  cases 
of  the  disease  had  occurred  weeks  or  months  before,  It  seems 
also  to  linger  about  the  persons  or  in  the  clothing  of  those  who 
have  had  the  disease  for  some  time  after  their  recovery.  Some 
recorded  instances  also  seem  to  show  that  the  contagion  may 

1  Loc.  cit. 


ETIOLOGY.  29 

be  carried  in  the  clothing-  of  those  who  have  been  exposed  to 
the  infection  of  the  disease,  but  not  affected  with  it  themselves, 
and  communicated  by  them  to  others. 

The  following-  is  one  of  many  such  instances :  Dr.  J.  H.  Sal- 
ter !  states  that  in  a  farm-house  situated  in  a  high  and  dry 
localit}',  and  several  hundred  yards  from  any  other  house,  a 
boy  of  eleven  years  was  attacked  with  diphtheria  on  October 
24th,  and  within  the  next  six  days  his  father,  another  child  and 
three  servants  came  down  with  the  disease.  There  was  no 
epidemic  in  the  neighborhood.  It  was  learned  on  investigation 
that  on  October  19th  a  woman  fromanotbi  r  village,  two  miles 
away,  had  brought  back  some  needlework  from  her  cottage, 
which  contained  at  the  time  two  sick  children.  One  child  had 
died  rather  suddenly  from  what  was  called  "bronchitis."  The 
other  was  seen  by  the  health-officer  with  well-marked  diphthe- 
ria. There  were  no  other  cases  for  miles  around.  The  infec- 
tion seems  to  have  been  carried  by  the  woman  in  her  clothing 
or  in  the  needlework.     She  did  not  herself  have  the  disease. 

The  contagion  of  diphtheria  may  probably  be  conveyed  by 
articles  of  food  and  drink,  such  as  milk,  etc.  Observations  in 
some  epidemics  of  diphtheria  have  seemed  to  establish  some 
connection  between  its  occurrence  and  the  milk-supply.  Some 
have  thought  it  probable  that  the  disease  known  as  garget  in 
cattle  might  be  a  source  of  diphtheritic  infection.  The  agency 
of  such  substances  as  carriers  of  diphtheria  is,  however,  not 
fully  demonstrated  and  is  probably  not  among  the  very  fre- 
quent causes  of  the  disease. 

That  diphtheria  occurs  epidemically  is  one  of  the  most 
notable  facts  in  connection  with  its  etiology.  It  is  evident 
that  at  such  times  the  contagion  of  the  disease  is  more  potent 
than  at  others,  as  it  is  propagated  and  disseminated  by  the 
various  modes  of  communication  which  have  just  been  enumer- 
ated independently  of  local  conditions,  and  with  an  intensity 
and  certainty  of  action  which  is  rarely  seen  in  connection  with 
1  British  Medical  Journal,  Dec  1,  1883. 


30         .    diphtheria;   its  nature  and  treatment. 

the  endemic  and  sporadic  forms  of  the  disease.  This  differ- 
ence in  respect  to  virulence  of  contagion  between  epidemic  and 
sporadic  or  endemic  cases  is  strikingly  illustrated  in  the  results 
of  the  experiments  of  Drs.  Wood  and  Formad  already  referred 
to.  Of  thirty-two  rabbits  inoculated  with  diphtheritic  matter 
from  endemic  cases  only  six  died,  and  none  of  those  from 
diphtheria;  of  fifteen,  inoculated  with  matter  from  the  Lu- 
dington  epidemic,  eleven  died,  and  four  of  these  with  abundant 
diphtheritic  exudation  at  the  site  of  inoculation.  It  is  not  im- 
probable that  many  of  the  discrepancies  in  the  results  of  ex- 
posures to  contagion  and  of  inoculation-experiments  may  be 
thus  accounted  for. 

It  is  next  in  order  to  inquire  what  is  the  nature  of  the 
contagium  of  diphtheria.  It  seems  probable  that  a  materies 
morbi  which  may  be  communicated  by  direct  contact  and 
by  inoculation,  which  may  be  suspended  in  and  conveyed  by 
the  atmosphere  and  by  gases  and  liquids,  which  may  be  shut 
up  in  apartments  and  adheres  for  a  considerable  time  to  walls 
and  furniture  and  persons  and  clothing,  and  which  is  repro- 
duced and  disseminated  in  the  course  of  tbe  disease  is  in 
the  form  of  solid  particles,  rather  than  of  a  liquid  or  a  gas,  or 
at  least  is  conveyed  by  such  particles.  This  may  also  be  in- 
ferred from  the  manner  in  which  the  disease  usually  commences 
upon  the  mucous  membrane  of  the  throat,  the  nares  or  the 
mouth,  namely,  in  points  or  in  small  limited  non-symmetrical 
areas  rather  than  with  the  general  diffusion  which  would 
characterize  the  action  of  an  inhaled  poisonous  gas  or  vapor 
either  acting  from  without  or  from  within  through  the  circu- 
lation. This  probability  is  also  sustained  by  the  results  of  ex- 
periments. Curtis  and  Satterthwaite 1  state  that  "  Thorough 
filtration  of  a  proven  virulent  aqueous  infusion  of  diphtheritic 
membrane  removes  the  infectious  property  of  the  same." 
And  the  same  results  have  been  reached  by  many  others. 

Is  this  contagium  a  chemical  poison  or  is  it  a  micro-organ- 

1  Loc.  cit. 


ETIOLOGY.  31 

ism,  or,  what  is  practically  equivalent  to  the  latter,  is  it  a 
chemical  poison  which  is  the  product  of  such  an  organism? 

Such  convincing- arguments  have  of  late  }Tears  been  brought 
forward  to  prove  that  the  phenomena  of  contagious  and  in- 
fectious diseases  can  be  fully  accounted  for  by  the  agency  of 
micro-organisms  and  in  no  other  way — arguments  which  are 
too  familiar  to  need  present  repetition — that  the  microbe  of 
diphtheria  has  long  been  eagerly  sought  for  by  many  and  its 
ultimate  discovery  confidently  anticipated  by  the  majority  of 
the  profession.  No  such  discovery  yet  supposed  to  have  been 
made  has  met  with  unchallenged  and  universal  acceptance; 
yet  in  the  course  of  the  search  various  facts  have  been  elicited 
of  such  interest  that  a  brief  review  of  them  is  essential  to  our 
present  inquiry. 

Professor  Laycock,1  in  1858,  was  the  first  to  find  a  supposed 
parasitic  cause  for  diphtheria  in  the  oidium  albicans.  Other 
microscopists  subsequently  observed  other  organisms  in  con- 
nection with  the  disease,  as  the  zygodesmus  fuse  as  of  Letze- 
rich 2  and  the  leptothrix  buccalis  of  Jaffe,3  which  were  in  turn 
found  to  be  common  to  other  diseases,  or  even  present  in  con- 
ditions of  health. 

In  1868  the  micrococcus, — an  organism  previously  observed 
by  Buhl — was  brought  forward  by  Oertel 4  as  the  specific  mi- 
crobe of  diphtheria.  The  micrococcus  is  a  minute,  point-like, 
dark-contoured,  round  or  oval  immovable  body,  occurring 
singly,  in  chains,  or  in  zooglea  (masses). 

According  to  the  earlier  observations  of  Oertel  the  micro- 
coccus was  always  accompanied  in  diphtheria  by  a  small  form 
of  the  bacterium  termo  (a  rod-bacterium).  He  stated  that 
these  organisms  were  always  to  be  seen  in  rapidly  increasing 
numbers  upon  the  mucous  membrane  at  points  where  diph- 
theritic   false    membrane   was    about  to   develop,  but   were 

1  Med.  Times  and  Gazette,  vol.  xxxviii.,  p.  548. 

2  Virchow's  Arch.  B.  xlv.  et  seq.  3  Schmidt's  Jahrbuch,  1862. 

4Studien  tiber  Diph.  Aertzl.  Int.,  1868.    No.  34. 


32  diphtheria;   its  nature  ant>  treatment. 

never  present  in  other  forms  of  inflammation,  that  they  pene- 
trated into  the  tissues,  caused  the  dissolution  of  the  young  cells, 
filled  and  obstructed  the  "blood  and  lymph -vessels,  appeared 
heaped  up  in  the  miniferous  tubules  and  the  Malpighian  cor- 
puscles of  the  kidneys,  and,  in  short,  were  found  in  the  most 
diverse  situations  and  were  inseparable  from  the  diphtheritic 
process.  The  observations  of  Oertel  were  more  or  less  fully 
corroborated  by  those  of  Von  Recklinghausen,  JSTassiloff,  Wald- 
eyer,  itlebs,  Eberth,  Heiberg,  Trendelenberg  and  Letzerich. 

These  views  were  controverted  by  Beale,1  Senator,2  Bill- 
roth,3 Curtis  and  Satterthwaite 4  and  others,  who  denied  the 


Fig.  1.— Diphtheritic  False  Membrane  Containing  Micrococci,  z,  Zooglea  formed  by  small 
micrococci;  s',  Zooglea  formed  by  larger  micrococci;  m,  Isolated  microbes.  X  500.  (Cornil 
and  Babes.) 

specific  character  and  the  pathogenic  function  of  these  para- 
sites in  diphtheria. 

The  observations  of  Wood  and  Formad,  already  referred 
to,  were  in  some  respects  in  accordance  with  those  of  Oertel, 
though  their  conclusions  were  somewhat  different.  In  freshly 
removed  false  membrane  micrococci  only  were  found  by  them. 
Other  forms  of  bacteria  were  found  in  membrane  which  had 
been  removed  some  hours  previously  or  which  was  removed 
post-mortem. 

In  examinations  of  the  blood  of  human  beings  during  life, 
micrococci  were  found  in  one  of  seven  cases  of  sporadic  diph- 

1  Disease  Germs.    London,  1872. 

2  Archiv.  Mr  pathol.  Anat.  und  Physiol.,  t.  lvi.,  1872. 

3  Untersuchungen  tiber  Vegetations-forinen  der  Cocco-baeteria  Sep- 
tica,  etc.    Berlin,  1874.  4  Op.  eit. 


ETIOLOGY.  33 

theria,  and  in  seven  of  fourteen  of  epidemic  diphtheria.  The 
seven  of  the  latter  class  in  which  they  were  not  found  were 
mild  or  in  the  stage  of  convalescence.  Micrococci  were,  how- 
ever, also  found  in  the  blood  during-  life  of  one  case  of  unknown 
disease  in  hospital  which  resulted  fatally,  and  in  two  of  scar- 
latina anginosa  with  exudation. 

"  Both  septic  animal  matter  and  non-organic  irritants  placed 
in  the  trachea  cause  pseudo-membranous  tracheitis,  which  we 
have  failed  to  distinguish  from  diphtheritic  tracheitis,  the 
membrane  in  both  cases  containing  micrococci.  The  occur- 
rence of  a  false  membrane  in  the  trachea  is  the  result  not  of 
the  specific  character  but  of  the  intensity  of  the  inflammation. 

"  The  micrococci  of  diphtheria  do  not  differ,  so  far  as  ob- 
served, from  the  micrococci  of  furred  tongue,  etc.,  except  in 
their  tendency  to  grow  in  culture  fluids. 

"The  micrococci  of  furred  tongue  or  ordinar}7  sore  throat 
have  a  less  tendency  to  grow  under  culture  than  have  the 
micrococci  of  endemic  non-malignant  diphtheria ;  and  the  lat- 
ter much  less  than  the  micrococci  of  malignant  diphtheria. 

"  The  rapidity  of  the  growth  of  the  micrococci  is  in  direct 
proportion  to  the  malignancy  of  the  case  yielding  them  and 
its  contagiousness. 

"  On  exposure  to  the  air  diphtheritic  membrane  of  the  most 
virulent  type  loses  its  contagious  power,  and  the  micrococci, 
pari  passu,  lose  their  power  of  growing  in  culture-fluids. 

"  Under  successive  generations  of  artificial  culture  the  diph- 
theria micrococci  lose  their  growth  activity  and  also  their 
power  of  infecting  the  rabbit. 

"  It  has  not  been  experimentally  directly  proven,  but  is  a 
necessary  inference  from  the  two  facts  just  stated,  that  under 
certain  favoring  circumstances  the  sluggish  micrococcus  puts 
on  growth  activity  and  in  all  probability  poisonous  properties. 

"Every  grade  of  case  may  be  found  in  man,  from  a  simple 
sore  throat  through  simple  membranous  pharyngitis  and  tra- 
cheitis up  to  malignant  diphtheria. 


34  diphtheria;  its  nature  and  treatment. 

"Any  inflammation  of  the  trachea  of  sufficient  intensity- 
may  cause  the  formation  of  a  pseudo-membrane. 

"A  case  may  beg-in  as  one  of  sthenic  '  pseudo-membranous 
croup/  and  end  as  one  of  adynamic  diphtheria  with  blood- 
poisoning-,  and  in  cases  of  this  character  not  infrequently  no 
exposure  to  contagion  is  discoverable,  and  there  is  clinically 
every  reason  to  believe  that  the e  blood-poison '  has  been  devel- 
oped within  the  body  of  the  patient.  The  theory  of  the  disease 
which  we  would  deduce  from  these  facts  is  that  the  micro- 
coccus which  directly  or  indirectly  causes  the  diphtheria  is 
not  a  specific  organism  different  from  that  common  to  healthy 
and  inflamed  throats,  but  is  an  active  state  of  that  organism ; 
that  certain  circumstances  outside  of  the  human  body  are 
capable  of  throwing  this  micrococcus  into  this  condition  of 
active  growth  and  engendering  an  epidemic  of  diphtheria. 
When  diphtheria  is  thus  epidemic  the  micrococci  light  upon  a 
throat,  and,  if  the  throat  have  little  resisting  power,  as  in  the 
child,  inflame  it,  or  increase  a  catarrh  already  existing  into  a 
violent  inflammation,  and  also  rapidly  enter  the  blood  and 
cause  systemic  poisoning.  On  the  other  hand,  a  catarrh  in  a 
weakly  subject  may  in  the  beginning  be  simply  an  inflamma- 
tion from  cold,  but  the  ordinary  micrococci  in  the  mouth  and 
throat,  favored  by  the  special  conditions,  may  gradually  change 
from  the  dormant  to  the  active  state,  and  by  and  by  act  upon 
the  throat  and  at  last  force  their  way  into  the  system,  and  a 
self -generated  diphtheria  be  formed  out  of  a  cold." 

This  theory  is  in  essential  accordance  with  that  stated  by 
Bindfleisch : x  "  The  apparently  sudden  outbreak  of  devastating 
plagues,  like  cholera,  syphilis  or  diphtheria,  is  best  explained 
by  supposing  that  a  fungus  growing  as  an  epiphyte  has  sud- 
denly gained  the  power  of  growing  as  an  endophyte,  thus  cre- 
ating an  apparently  new  infection." 

Other  forms  of  bacteria  have  been  found  by  various  inves- 
tigators in  apparent  pathogenic  relation  to  diphtheria.  Among 
"  Elements  of  Pathology." 


ETIOLOGY.  35 

these  is  the  "  tilletia  diphtheritica,"  a  later  discovery  of  Letze- 
rich l  than  the  zygodesmus  fuscus.  Another  is  the  "  microspo- 
ron  diphtheriticum-/'  described  by  Klebs 2  as  consisting-  of  small 
micrococci  compacted  in  round  balls,  surrounded  with  a  thin 
layer  of  gelatinous  matter.  These  subsequently  develop  into 
minute  motile  bacilli,  and  finally  into  tufts  of  mycelium. 

Klebs  stated  at  the  German  Medical  Congress  in  1883,  that 
he  had  found  this  form  of  bacteria  in  connection  with  a  grave 
form  of  diphtheria  at  Prague,  which  was  characterized  by 
prominent  nervous  symptoms  and  hemorrhagic  formations  in 
the  brain  and  spinal  cord  on  post-mortem  examination.  As 
he  had  found  these  organisms  transmittible  to  the  cornea,  he 
had  regarded  them  as  the  specific  fungi  of  diphtheria. 

Later,  however,  at  Zurich  he  had  seen  cases  of  diphtheria 
of  an  entirelj*  different  character.  The  false  membrane  of  the 
throat  had  a  great  tendency  to  extend  into  the  larynx  and 
trachea,  followed  by  interstitial  inflammatory  processes  in  in- 
ternal organs.  The  micro-organisms  in  these  cases  were  of 
an  entirely  different  character  from  those  found  in  former 
ones.  Instead  of  being  globular  they  were  exclusively  bacil- 
lar  formations.  Hence  he  had  distinguished  two  forms  of  diph- 
theria— the  diphtheria  microsporon  and  diphtheria  bacillaris. 

M.  Talamon,  in  January,  1881,  gave  to  the  Anatomical  So- 
ciety of  Paris  a  minute  description  of  still  a  different  bacterium 
which  he-  had  discovered  in  connection  with  diphtheria,  and 
which  appears  under  the  form  of  mycelia  and  characteristic 
spores.  Talamon  had  produced  diphtheria  (or  an  affection 
having  all  its  essential  features)  in  rabbits,  guinea-pigs,  cocks 
and  pigeons  by  inoculating  them  with  this  fungus,  and  in  frogs 
by  simply  feeding  them  with  it. 

Emmerich 3  arrived  at  yet  different  results.  The  organism 
which  he  found  to  occur  distinctively  in  the  diphtheritic  lesions 
of  both  man  and  pigeons  was  neither  a  coccus  nor  a  bacillus, 

'Loc.  cit.        2Archiv.  f.  exper.  Pathol,  und  Therap.,  vol.  iv.,  p.  191. 
3Deutsch.  Med.  Wochenschr.  1884,  No.  38. 


36  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

but  a  short  thick  bacterium.  Inoculated  from  cultures  into 
pig-eons,  rabbits  and  mice,  these  bacteria  produced  character- 
istic local  diphtheritic  lesions  and  a  rapidly  fatal  general  dis- 
ease. 

The  most  important  bacteriological  investigations  which 
have  yet  been  made  in  connection  with  diphtheria  are  those 
of  Dr.  Friedrich  Loeffler.1  Attributing  the  unsatisfactory  re- 
sults of  previous  attempts  to  discover  the  specific  microbe  of 
diphtheria  to  the  inherent  difficulties  attending  them,  from 
the  great  number  of  different  fungi  present  in  the  disease,  and 
also  to  the  insufficient  methods  which  had  been  employed, 
since  only  impure  material  had  been  used  in  cultures  and  in- 
oculations without  separation  of  the  different  organisms,  he 
was  therefore  induced  to  apply  the  more  accurate  methods  of 
Koch  to  the  investigation.  He  first  made  histological  exami- 
nations, with  an  improved  method  of  staining,  of  the  affected 
mucous  membranes  and  internal  organs  of  twenty-seven  pa- 
tients who  had  died  of  diphtheria,  including  five  cases  of  scar- 
latinal diphtheria.  In  these  examinations  he  found  two  forms 
of  bacteria  especially  numerous,  viz.,  micrococcci  in  chains 
(streptococci)  and  a  form  of  bacillus.  The  micrococci  were 
not  present  in  all  cases.  They  were  probably  the  same  which 
had  previously  been  so  generally  observed  in  diphtheria. 

They  were  found  not  only  on  and  in  the  affected  mucous 
membranes  in  some  cases,  but  also  in  the  lymphatics,  whence 
they  penetrated  to  every  part  of  the  body,  causing  necrosis  of 
the  tissues.  Micrococci  morphologically  identical  with  these 
are,  however,  also  found  in  various  other  diseases  which  are 
accompanied  with  lesions  of  the  mucous  membranes,  such  as 
variola,  typhoid  and  puerperal  fever,  etc.,  in  which  diseases 
their  presence  is  regarded  as  entirely  accidental. 

:  Mittheilungen  aus  dem  k.  Gresundheitsante,  Berlin,  vol.  ii.,  1884. 
Abstracted  by  Dr.  J.  W.  Hiine  in  "  Microparasites  in  Disease,"  New 
Sydenham  Soc,  1886,  and  by  Dr.  M.  Putnam- Jacobi,  in  the  Quarterly 
Bulletin  of  the  Clinical  Society  of  the  New  York  Post-Graduate  Medi- 
cal School  and  Hospital,  August,  1885. 


ETIOLOGY.  37 

The  bacilli  were  probably  the  same  which  had  been  first 
described  by  Klebs.  They  are  non-motile,  either  straight  or 
curved,  about  the  length  of  the  bacillus  of  tubercle,  but  twice 
as  thick.  They  were  found  exclusively  in  those  typical  cases 
of  diphtheria  which  were  characterized  by  thick  false  mem- 


raft  /ft&A 


Fi&.  2.— The  Streptococci  found  by  Loeffler  in  Diphtheria.    X  1250. 

brane  in  the  fauces,  larynx  and  trachea.  In  this  false  mem- 
brane they  were  very  numerous,  and  they  were  found  in  deeper 
layers  of  it  than  were  the  micrococci  and  other  accidental  bac- 
teria, which  only  occurred  superficially.  The  bacilli  were  not 
found  in  the  internal  organs,  the  blood-vessels  or  the  lymphat- 
ics, and  if  they  are  really  the  cause  of  diphtheria,  they  are  so 
not  by  themselves  penetrating1  the  system,  but  by  producing 
a  poison  which  first  acts  locally,  producing  tissue  necrosis, 
vascular  paralysis  and  dilatation,  and  exudation  of  fibrogenous 

^_,r/§;  "v.;. .;;,-"% 

~~      '  ^"^^    ^ci-IiTv,  "■'■■7-' 


Fig.  3. — Bacilli  on  the  Surface  of  False  Membrane  of  Vulvar  Diphtheria,  and  in  a  Crevice 
between  the  Filaments  of  Fibrin  which  compose  it.    X  400.    (Cornil  and  Babes.) 

lymph,  and  then  entering  the  circulation  causes  the  constitu- 
tional disease. 

The  bacilli  were  not  found  in  all  typical  cases.  It  was, 
however,  possible  that  they  might  have  been  present,  but  have 
died  and  been  eliminated  before  the  patient's  death.     The  re- 


38        DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 

suits  of  the  histological  investigations  were  upon  the  whole  in- 
conclusive. 

The  bacteria  described  were  next  cultivated  by  the  usual 
processes  for  isolation  from  the  fourth  to  the  twenty-fifth  gen- 
eration. 

The  products  of  these  cultures  were  then  inoculated  upon 
mice,  guinea-pigs,  rabbits,  monkeys  and  birds. 

Inoculations  with  the  streptococci  in  no  instance  produced 
a  disease  even  resembling  diphtheria.  For  this  and  other  rea- 
sons Loeffler  concluded  that  they  cannot  be  regarded  as  the 
specific  cause  of  the  disease,  though  it  is  probable  that  they 
may  under  some  circumstances  produce  a  disease  resembling 
diphtheria. 

Cultivations  of  the  bacilli  introduced  beneath  the  skin  of 
guinea-pigs  and  small  birds  killed  them,  producing-  whitish  or 
hemorrhagic  exudations  at  the  point  of  inoculation,  and  exten- 
sive subcutaneous  oedema,  the  internal  organs  being  unaffected. 
Inoculated  in  the  trachea  of  rabbits,  fowls  and  pigeons,  or  the 
vagina  of  guinea-pigs,  the  poison  produced  a  false  membrane. 
There  was  also  the  characteristic  alteration  of  the  vascular 
walls  which  shows  itself  by  bloody  oedema,  hemorrhage  into 
the  tissue  of  the  lymphatic  glands  and  effusion  into  the  pleural 
cavity.  The  bacilli  have,  therefore,  the  same  effect  as  the 
diphtheritic  virus. 

Their  specific  character  is  seemingly  opposed  by.the  follow- 
ing facts :  They  were  absent  in  a  number  of  undoubted  cases 
of  diphtheria;  they  were  not  present  in  typical  quantity  and 
arrangement  in  the  artificially  produced  pseudo-membranes; 
they  had  no  effect  when  applied  to  the  uninjured  surface  of 
mucous  membranes  in  some  animals  otherwise  susceptible  to 
their  action;  animals  which  survived  showed  no  paralysis; 
identical  bacilli  were  found  in  the  saliva  of  healthy  children. 
Proof  that  these  bacilli  are  the  cause  of  diphtheria  is  therefore 
incomplete,  though  the  possibility  of  their  being  so  is  not  ex- 
cluded. 


ETIOLOGY.  39 

The  investigations  of  Babes  *  in  twenty-four  cases  of  diph- 
theria confirmed  in  a  general  sense  the  observations  of  Loeffler. 
In  every  case  there  were  streptococci  and  the  bacilli  of  Loeffler. 
In  the  cultures  made  from  false  membranes  the  streptococci 
were  more  numerous,  but  the  bacilli  invaded  and  overwhelmed 
them,  remaining-  finally  the  sole  masters  of  the  field. 

The  bacilli  were  found  in  the  depth  of  the  tonsils  in  dense 
masses,  and  sometimes  in  the  retro-pharyngeal  g-anglia.  In 
the  bronchial  ganglia  streptococci  only  were  found.  These 
bacteria  were  in  some  cases  accompanied  by  other  pathog-enic 
microbes — the  staphylococcus  aureus  and  an  encapsulated  mi- 
crobe resembling  that  of  pneumonia. 

In  cutaneous  diphtheria  bacilli  were  observed  not  only  in 
the  false  membrane,  but  also  on  the  free  surface  of  the  papilla?, 
and  in  smaller  numbers  in  the  connective  tissue  and  the  di- 
lated vessels  of  the  inflamed  papilla?,  and  more  rarely  in  the 
tissue  of  the  derma. 

In  reference  to  the  organisms  of  human  diphtheria,  Cornil 
and  Babes  say:  "We think  that  the  bacilli  of  Klebsand  Loeff- 
ler ma3r  be  regarded  as  the  most  important  agents  in  the 
production  of  the  false  membrane  of  true  diphtheria,  but  it 
must  be  admitted  that  physiological  researches  in  the  case  of 
that  disease  have  not  yet  given  their  final  response/' 

Dr.  A.  D'Espine,2  President  of  the  Medical  Society  of  Ge- 
neva, has  found  the  bacillus  of  Loeffler  in  every  one  of  fourteen 
cases  of  diphtheria  and  croup,  and  absent  in  all  of  twenty-four 
cases  of  simple  anginas  studied  by  him.  In  a  case  of  croup  a 
pure  culture  was  obtained  which  preserved  its  pathogenic 
powers  through  twenty-five  generations,  as  was  proved  by 
inoculation  experiments.  Dr.  D'Espine  believes  that  this  is 
the  pathogenic  organism  of  diphtheria  and  croup,  that  it  pro- 

1  *'  Les  Bacteries  et  leur  role  dans  ranatornie  et  l'histologie  patholog- 
iques  des  maladies  infectieuses,"  par  A.  V.  Cornil  et  V.  Babes.  Paris. 
18S6,  p.  458. 

-  Revue  Medieale  de  la  Suisse  Romande,  No.  1.  January.  1888,  p.  49. 


40  DIPHTHERIA;    ITS    NATURE    AND    TREATMENT. 

duces  a  leucomaine  which,  when  absorbed,  gives  rise  to  the 
systemic  poisoning,  and  that  its  presence  or  absence  may  be  a 
reliable  diagnostic  criterion. 

On  the  other  hand,  Von  Hoffmann- Wellenhoff x  has  found 
the  bacillus  of  diphtheria  of  Loeffler  in  seven  cases  of  pharyn- 
geal diphtheria,  in  three  cases  of  measles,  in  six  out  of  nineteen 
cases  of  pharyngitis  complicating  scarlatina,  and  in  four  out 
of  eleven  cases  which  had  no  perceptible  abnormalities.  Tests 
in  regard  to  the  virulence  of  cultures  of  these  bacteria  showed 
that  a  number  of  those  which  were  obtained  from  diphtheritic 
as  well  as  non-diphtheritic  cases  caused  in  animals  the  symp- 
toms described  by  Loeffler,  while  other  cultures  morpholog- 
ically identical  with  them  were  perfectly  harmless  in  the  ex- 
periments made. 

•  Oertel  in  his  late  important  work,  Die  Pathogenese  der 
Epidemischen  Diphtherie,  Leipzig,  1887,  page  141,  et  seq.,  re- 
ferring to  his  former  statement  (previously  quoted)  that  he 
had  always  found  the  micrococcus  accompanied  in  diphtheria 
by  a  rod-bacterium,  states  that  this  rod-bacterium  and  the 
bacillus  of  Klebs  and  Loeffler  very  nearly  coincide  in  their 
measurements,  and  also  in  the  knobbed  appearance  of  one  or 
both  of  their  extremities,  and  are  in  all  probability  iden- 
tical. 

A  new  series  of  observations  by  Oertel  on  the  micro-organ- 
isms present  in  diphtheritic  membrane,  maybe  roughly  stated 
as  in  general  correspondence  with  those  of  Loeffler. 

In  a  recent  series  of  post-mortem  examinations  Oertel  has 
failed  to  find  micrococci  present  in  the  kidneys  in  any  case. 
This  difference  from  his  earlier  observations  he  explains  by 
the  fact  that  the  more  recent  cases  have  been  of  a  less  markedly 
septic  type  than  the  former  ones. 

While  these  facts  obviously  suggest  the  hypothesis  that 
diphtheria  is  the  result  of  a  mixed  infection  by  specific  bacilli 

Archives  of  Paediatrics,  January,  1889,  from  Jahrb.  f.  Kinderh., 
xxviii.,  3. 


ETIOLOGY. 


41 


and  septic  micrococci,  Oer- 
tel  does  not  consider  that 
this  conclusion  is  as  yet  ful- 
ly established. 

Oertel  also  states  that 
no  bacteria  can  be  found  in 
diphtheria  in  the  interior  of 
the  diseased  cells  in  any  sit- 
uation, nor  in  the  necrobio- 
tic  foci  at  any  stage,  nor  in 
the  parenchyma  of  the  in- 
ternal organs,  nor  on  their 
surface  in  such  situations  as 
make  it  probable  that  they 
are  the  immediate  cause  of 
the  disease.  Hence  it  is  to 
be  inferred  that  their  mor- 
bific action  must  be  due  to 
the  chemical  poisons  or 
ptomaines  which  they  cause 
to-be  produced  in  the  sub- 
stances in  which  they  live. 
He  believes  that  this  poison 
or  virus  first  passes  into 
and  through  the  epithelium, 
induces  alterations  in  the 
tissue -fluids,  excites  irrita- 
tion and  inflammation,  and 
thus  inaugurates  the  train 
of  morbid  and  necrobiotic 
processes  which  is  elsewhere 
described.  In  the  course  of 
these  processes  the  poison 
is  reproduced  both  by  the 
multiplication   of    bacteria 


FN. 


££-_ '.,„  -^'  ■•-:- C-'-%  v  \ 

fBZ. 

Fig.  4.— The  Extension  of  Bacteria  into  the  Fi- 
brinous Exudation.  (Oertel.)  B.  V.,  bacterial  vege- 
tations; F.N.,  fibrinous  network;  L,  leucocytes, 
their  degeneration,  division  and  disintegration  be- 
ing indicated  to  a  slight  extent  only;  B.Z  ,  chains 
of  rod-shaped  bacteria  with  knobbed  extremities. 


42  DIPHTHERIA;    ITS   NATURE    AST)    TREATMENT. 

and  by  fermentation-changes  in  the  decomposing-  substances, 
and  becomes  more  and  more  widely  diffused. 

Diphtheria,  as  a  general  rule  which  is  subject  to  relatively 
very  few  exceptions,  occurs  only  on  those  surfaces  of  the  body 
which  are  exposed  to  the  access  of  the  air.  This  suggests  that 
among  the  conditions  which  are  usually  necessary  to  produce 
it  is  the  presence  of  free  oxygen.  Bacteria,  according  as  the 
presence  of  free  oxygen  is  necessary  or  hurtful  to  them,  are 
classed  as  aerobious  or  anaerobious.  From  the  circumstance 
just  referred  to  it  has  been  inferred  that  the  bacterium  of  diph- 
theria is  aerobious.  Dr.  B.  K.  Bachford,1  in  taking  this  view, 
suggests  that  the  occasional,  but  rare,  occurrence  of  diphthe- 
ria in  the  stomach  and  intestines,  where  free  oxygen  is  not 
present,  may  take  place  under  exceptional  conditions  in  which 
oxygen  is  supplied  in  some  unstable  combination  in  which  it 
may  be  utilized  for  the  sustenance  of  the  bacteria  of  the  dis- 
ease, and  that  that  condition  may  be  one  of  congestion  and 
erosion  of  the  gastric  or  intestinal  mucous  membrane,  in  which 
the  oxygen  is  thus  supplied  by  the  oxyhemoglobin  of  the  blood. 
In  proof  that  this  explanation  is  not  far-fetched  he  cites  the 
fact  that  strictly  aerobic  germs,  such  as  anthrax,  live  and  mul- 
tiply in  the  body,  deriving  their  oxygen  from  this  source. 

The  search  for  the  specific  bacterium  of  diphtheria  has  been 
stimulated  by  the  general  belief  that  diphtheria  is  a  specific 
disease  like  scarlatina  or  small-pox,  which,  according  to  prev- 
alent theories,  must  have  a  single  parasitical  cause.  The  Iry- 
pothesis  that  it  may,  on  the  other  hand,  include  several  gen- 
erically  related  and  resembling  septic  processes  with  specific 
differences  and  dependent  on  the  action  not  of  one  but  of  vari- 
ous bacteria,  has  been  entertained  by  some  and  is  perhaps,  at 
the  present  imperfect  stage  of  our  knowledge,  worthy  of  a 
moment's  consideration  It  is  not  inconceivable  that  croupous 
and  diphtheritic  inflammation  maybe  capable  of  being  excited 
by  the  action  of  more  than  one  kind  of  bacterium,  as  it  is 
1  Medical  News,  Feb.  2,  1889. 


ETIOLOGY.  43 

known  that  morbid  processes  closely  resembling"  them  may  be 
by  various  chemical  and  mechanical  agencies. 

This  supposition  is  favored  by  the  remarkable  differences 
which  have  been  observed  in  the  form  and  course  of  these  proc- 
esses. The  differences  in  the  clinical  features  and  the  patho- 
logical lesions  of  constitutional  diphtheria  are  even  more  strik- 
ing, and  although  in  the  majority  of  cases  they  conform  to 
certain  general  types,  yet  the  deviations  from  those  types  are 
in  some  instances  so  wide  that  they  would  seem  to  be  more 
readily  explicable  by  the  hypothesis  of  different  infections,  or 
"  mixed  "  infections,  than  by  any  other.  That  mixed  infections 
or  intoxications  should  occur  through  a  favorable  habitat 
being  afforded  to  some  pathogenic  organisms  by  tissue  changes 
previously  caused  by  others,  or  the  conversion  thereby  of  pre- 
viously innocuous  to  pathogenic  ones  is  in  accordance  with 
many  known  facts. 

It  can  hardly  be  doubted  that  the  important  questions 
thus  suggested  respecting  the  etiology  of  the  various  forms 
and  complications  of  diphtheria,  will  ere  long  be  finally  an- 
swered by  the  multiplication  of  precise  investigations. 

The  following  conclusions  from  facts  and  considerations 
which  have  now  been  presented  may  be  regarded  as  probable : 

1.  Diphtheria  is  caused  by  a  parasite  which  has  the  follow- 
ing characteristics :  Its  growth  and  multiplication  outside  of 
the  body  are  favored  by  dampness  and  insanitary  conditions, 
and  it  is  reproduced  in  the  disease;  its  presence  on  mucous 
membranes  is  sometimes  innocuous;  its  vital  activity  is  greatly 
increased  under  the  conditions  which  prevail  during  an  epi- 
demic; its  pathogenic  action  is  greatly  favored  by  pre-existing 
morbid  conditions  of  the  body,  and  especially  those  involving 
lesions  of  the  epithelium ;  it  is  transmitted  from  one  person  to 
another  by  the  various  processes  which  are  most  usually  in- 
cluded under  the  terms  contagion  and  infection. 

2.  This  parasite  causes  diphtheria  by  being  implanted  on  a 
mucous  membrane  or  a  wounded  surface  of  the  body  or  in  its 


44  diphtheria;  its  nature  and  treatment. 

more  superficial  tissues,  and  there  producing-  a  chemical  poi- 
son, or  ptomaine. 

3.  This  poison,  or  ptomaine,  toy  its  direct  action  on  the  tis- 
sues and  vessels  causes  the  local  diphtheritic  process,  in  the 
course  of  which  it  is  reproduced  and  more  and  more  widely 
diffused,  and  toy  its  absorption  from  this  source  into  the  gen- 
eral circulation  causes  the  constitutional  disease. 

4.  This  morbid  process  is  often  accompanied  or  followed  toy 
the  invasion  of  the  toody  by  other  pathogenic  bacteria,  to  which 
various  complications  are  due. 

5.  No  toacterium  thus  far  discovered  in  connection  with 
diphtheria  can  furnish  toy  its  presence  or  its  atosence  a  reliatole 
criterion  for  diagnosis. 

Incubation. —  The  period  of  incubation  in  diphtheria — that 
is,  the  time  from  the  actual  reception  of  the  contagium  into 
the  system  to  the  appearance  of  the  disease — is  for  otovious 
reasons  in  the  great  majority  of  cases  impossible  to  ascertain. 
The  only  cases  in  which  it  can  be  accurately  estimated  are 
those  in  which  the  disease  is  known  to  result  from  a  single  ex- 
posure of  short  duration,  and  even  in  these  cases  there  is  an  ele- 
ment of  uncertainty,  since  there  is  reason  to  believe  that  the 
germ  of  the  disease  may  toe  carried  about  the  person  innocu- 
ously— perhaps  even  on  the  buccal  mucous  membrane — for 
some  time  before  it  begins  to  exert  a  morbific  influence. 

There  are,  however,  abundant  data  for  estimating  the  min- 
imum period  of  incubation  in  instances  in  which  the  disease  has 
been  brought  to  the  members  of  a  family  or  a  school,  or  the 
inmates  of  a  hospital,  by  persons  affected  with  it.  My  own 
observation  in  many  such  instances  corroborates  that  of  most 
authors  that  the  minimum  period  of  incubation  is  usually  about 
two  cla3rs.  Dr.  Morell  Mackenzie 1  relates  an  instance  in  which 
a  child  had  the  disease  with  abundance  of  false  membrane  the 
next  morning  subsequent  to  the  afternoon  of  her  first  exposure, 
and  another,  equally  definite,  in  which  the  interval  between  ex- 

1  Op.  cit.  p.  29. 


ETIOLOGY.  -15 

posure  and  the  development  of  the  disease  was  fifteen  days. 
A  child  in  a  family  which  had  a  few  weeks  before  removed  from 
a  village  in  Pennsylvania  where  there  had  been  no  diphtheria 
to  a  neighborhood  in  this  city  where  diphtheria  was  endemic, 
took  the  disease.  During  her  illness  her  father,  who  had  re- 
mained behind,  joined  his  family  and  at  once  devoted  himself 
to  the  care  of  the  child.  The  second  morning  (less  than  two 
days)  after  his  arrival  he  came  to  me  complaining  of  sore 
throat,  and  proved  to  be  suffering  from  diphtheria.  The  usual 
period  of  incubation  in  diphtheria,  in  the  sense  in  which  the  term 
is  defined  above,  is  probably  from  two  to  five  or  six  days, 
though  the  interval  between  exposure  and  the  resultant  disease 
may  be  several  weeks. 

In  1876  I  saw,  with  Dr.  J.  E.  Janvrin,  of  this  city,  a  case  of 
diphtheria  at  Dobbs'  Ferry,  of  which  the  history  was  as  follows : 
Mrs.  H.,  with  her  son,  aged  seven,  and  his  nurse,  went  on  Sep- 
tember 1st  to  a  hotel  at  Long  Branch.  On  September  10th 
Mrs.  H.  was  there  attacked  with  diphtheria.  There  had  pre- 
viously been  other  cases  in  the  hotel.  The  child  and  nurse 
were  at  once  sent  to  their  home  at  Dobbs'  Ferry,  and  Mrs. 
H.  came  to  a  hotel  in  this  city,  where  she  was  attended  by 
Dr.  Janvrin  from  September  11th  to  19th  through  a  severe 
attack  of  pharyngeal  diphtheria.  She  returned  to  her 
home  on  October  1st.  On  October  24th  her  son  was 
attacked  with  a  most  malignant  form  of  the  disease,  which 
terminated  fatally.  The  probabilities  in  this  case  were  either 
that  the  child  had  carried  about  himself  the  germs  of  the  dis- 
ease for  forty-four  days  or  that  he  had  received  them  from  his 
mother  within  the  twenty-three  days  before  his  attack  and  at 
least  twelve  days  after  her  recovery.  There  had  been  no  pre- 
vious cases  of  the  disease  at  that  time  at  Dobbs'  Ferry. 

[Some  recent  important  contributions  to  the  etiology  of 
diphtheria  are  appended  at  page  259.] 


CHAPTER  III. 

PATHOLOGY. 

Diphtheritic  false  membrane  may  be  generally  described 
as  a  somewhat  tough,  firm,  compact,  elastic  substance.  Its 
color  is  a  yellowish  or  grayish  white.  In  thickness  it  varies 
from  that  of  a  mere  pellicle  to  two  or  three  millimetres,  and  in 
extent  from  a  minute  patch  to  a  coating  of  the  whole  surface 
of  the  mouth  and  throat  or  a  lining  of  the  air-passages.  In 
texture  it  is  usually  irregularly  fibrillated,  but  is  sometimes 
amorphous  or  granular  or  lamellated,  and  these  conditions  are 
often  intermingled.  It  is  tasteless  and  odorless,  is  insoluble 
in  water,  is  dissolved  by  caustic  alkalies,  swells  up  and  be- 
comes transparent  under  the  addition  of  acetic  acid,  and  in  its 
physical  and  chemical  properties  closely  resembles  fibrin. 

Under  the  microscope  false  membrane  is  seen  to  consist  of 
a  network  of  fibrinous  threads  of  varying  thickness  and  close- 
ness, in  the  meshes  or  interstices  of  which  are  cells,  namely 
leucocytes,  red  globules  or  epithelial  cells,  which  have  usually 
undergone  a  peculiar  necrotic  transformation.  The  relative 
proportions  of  these  elements  vary  greatly  in  different  cases. 

Diphtheritic  false-membrane  was  regarded  by  the  older 
writers  as  a  gangrenous  eschar,  by  Samuel  Bard  as  altered 
and  inspissated  mucus,  by  Bretonneau  and  his  successors  as  a 
coagulated  fibrinous  exudation  analogous  to  that  which  occurs 
on  the  surface  of  serous  membranes.  It  will  be  seen  that  there 
was  an  element  of  truth  in  all  of  these  views. 

According  to  E.  Wagner 1  false  membrane  is  the  result  of 
a  peculiar  necrobiotic  metamorphosis  in  the  epithelial  cells, 
1  Archiv.  f.  Heilkunde,  1866,  Bd.  vii.,  p.  481. 


PATHOLOGY.  47 

which  become  enlarged,  porous  and  irregular  in  shape,  sending" 
out  peripheral  projections  which  unite  with  those  of  adjoining- 
cells,  forming  a  homogeneous  network  in  which  nuclei  can  no 
longer  be  detected,  and  an  accompanying  infiltration  of  the 
corion,  and,  in  some  cases,  the  subjacent  tissues,  with  new  cells 
and  nuclei  and  sometimes  extravasated  blood. 

Buhl 1  observed  also  an  infiltration  of  the  tissue  of  the  mu- 
cosa, even  in  situations  where  it  was  not  covered  by  false 
membrane,  with  cellular  or  nucleolar  bodies.  This  infiltration 
he  found  widely  diffused  through  various  organs  and  regarded 
as  characteristic  of  diphtheria. 

Boldyrew 2  and  Steudener 3  opposed  the  views  of  Wagner 
as  not  confirmed  by  their  observation,  and  assigned  a  leading 
place  in  the  formation  of  diphtheritic  membrane  to  vascular 
exudation. 

Both  of  the  processes  just  referred  to,  namely,  fibrinous 
exudation  and  the  necrotic  metamorphosis  of  cells  and  tissues, 
are  included  in  more  recent  views  of  the  formation  of  diphthe- 
ritic membrane. 

The  precise  circumstances  which  in  all  cases  favor  or  pre- 
vent the  coagulation  of  inflammatory  exudations  upon  the 
surface  of  mucous  membranes  are  not  fully  known.  Weigert 4 
has  shown  that  in  order  that  it  may  take  place  the  epithelium 
must  be  wholly  or  partially  destroyed. 

The  coagulation  of  fibrin  is  not  a  mere  solidification  of  a 
substance  which  previously  existed  as  such  in  solution  in  the 
effused  fluids,  but  is  a  new  formation  from  the  fibrin-generators 
which  they  contain.  According  to  Alexander  Schmidt  the 
plasma  of  the  blood  contains  fibrinogen,  and  the  white  corpus- 
cles and  probably  other  cells  furnish  fibrinoplastin  and  a  fer- 
ment. When  the  white  corpuscles  die  and  are  dissolved  in  the 
plasma  the  result  is  the  production  of  fibrin. 

'Zeitsehr.  f.  Biol.,  Bd.  iii.,  S.  349.  1867. 
2  Archiv.  f.  Anat.  u.  Phys.,  1872.  p.  75. 
3Virch.  Archiv.,  1872,  liv.,  p.  500. 
4Virch.  Archiv.,  Bd.  lxxix. 


48  diphtheria;  its  nature  and  treatment. 

The  peculiar  metamorphosis  of  cells  and  tissues  which 
occurs  in  the  formation  of  pseudo-membrane  was  named  by 
Cohnheim  coagnlative  necrosis,  and  its  nature  was  made  known 
to  us  chiefly  by  Weigert.  It  is  a  coagulation  which  occurs  not 
only  in  effused  vital  fluids,  but  in  the  substance  of  cells  and 
tissues.  That  it  shall  take  place  it  is  necessary  that  the  cells 
or  tissue  elements  shall  die  or  be  in  the  process  of  necrotic  de- 
generation, and  that  then  effused  lymph  shall  flow  through 
them.  Fibrin  is  formed  within  the  tissue  by  the  union  of  its 
two  components  just  referred  to.  The  death  of  the  cells  or  tis- 
sues may  be  the  result  of  injury  from  physical  or  chemical  or 
thermal  agencies  or  from  arrested  nutrition;  the  effusion  of 
lymph  is  due  to  the  vascular  changes  which  accompany  inflam- 
mation. 

Rindfleisch1  says: 

"  Coagulation  necrosis  is  to  be  distinguished  from  the  sim- 
ple death  of  a  part  by  the  presence  of  a  coagulated  albuminous 
liquid  which  accompanies  the  transition  from  life  to  death  in 
the  cells  and  tissues.  This  liquid  bears  such  a  strong  resem- 
blance to  coagulated  fibrin  that  one  is  tempted  to  consider 
them  the  same,  except  that  the  macroscopical  and  microscopi- 
cal examination  proves  that  the  coagulation  is  chiefly  present 
in  the  interior  of  the  cells  and  in  other  constituents  of  the  tis- 
sues. The  microscope  shows  a  peculiar  homogeneous  tendancy 
of  the  cell-protoplasm,  accompanied  by  a  total  disappearance 
of  the  nucleus.  Thus  the  cells  lose  their  sharp  outline  and  be- 
come flaky  masses,  inclined  to  adhere  to  each  other  and  fall 
into  large  irregular  formations  of  membranous  consistency. 
The  frequent  wax-like  appearance  of  these  coagulations  is  a 
peculiar  feature,  indicating  their  thorough  impregnation  with 
a  strong  refractive  albuminous  body." 

Virchow  divided  the  process  by  which  false  membrane  is 
produced,  and  the  resulting  false  membranes  themselves,  into 
two  principal  classes,  the  croupal  and  the  diphtheritic.  Croupal 
1 "  Elements  of  Pathology." 


PATHOLOGY. 


49 


false  membrane  may  be  roughly  stated  to  be  that  which  lies 
superficially  and  loosely  upon  the  mucous  membrane  affected, 
and  is  mainly  a  fibrinous  exudation;  the  diphtheritic  that 
which  penetrates  it  more  or  less  deeply,  and  is  in  reality  an 
eschar  in  it  or  even  beneath  it.  This  classification  is  now  gen- 
erally admitted  to  be  based  on  differences  in  degree  and  in  ana- 
tomical relations  rather  than  in  essential  pathological  nature. 

Ziegler  describes  the  various  processes  by  which  false  mem- 
brane is  formed  and  their  products,  according  to  views  now- 
prevailing,  with  such  clearness  that  I  shall  quote  from  his 
statements : 

"Croupous  Inflammation.1 — When  a  mucous  membrane 


Fig.  5.-  Croupous  Membrane  from  the  Trachea,  (x  250.)  a,  section  through  the  false 
membrane;  b,  upper  layer  of  the  mucous  membrane,  infiltrated,  with  pus-corpuscles  (d);  c, 
filaments  and  granules  of  fibrin;  d, pus-corpuscles. 


is  so  injured  that  its  epithelium  is  here  and  there  partially  de- 
stroyed, and  at  the  same  time  its  blood-vessels  are  so  damaged 
that  an  abundant  exudation  is  poured  out  on  the  surface,  co- 
agulation of  the  latter  may  take  place.  In  this  way  a  pale 
yellowish  membrane  is  formed  on  the  surface,  consisting  of 
fibrinous  filaments  and  granules  beset  with  pus-corpuscles,  or 
of  shining  homogeneous  blocks  representing  cells  which  have 
undergone  coagulative  necrosis.  This  false  membrane  is  con- 
nected with  the  underlying  structures  by  fibrinous  threads, 
but  is  usually  loosely  adherent  and  can  be  readily  stripped  off, 
disclosing  the  reel    hyperamiic  mucous   membrane   beneath. 

1 "  Text  Book  on  Pathological  Anatomy  and  Pathogenesis,"  Section  423. 
4 


50 


DIPHTHERIA;    ITS   NATURE    AND    TREATMENT. 


The  epithelial  cells  are  always  more  or  less  injured,  being  either 
necrotic  or  in  process  of  degeneration  and  desquammation. 
The  fibrous  structure  of  the  inflamed  mucous  membrane  al- 
ways contains  liquid  and  cellular  exudations. 

"  Diphtheritic  Inflammation. — When  a  mucous  membrane 
is  injured  in  such  a  way  that  its  epithelium  dies  without  des- 
quamation, while  its  blood-vessels  are  damaged  and  pour  out 
an  abundant  exudation,  it  sometimes  happens  that  the  dead 
epithelial  cells  become  saturated  with  the  exuded  liquid  and 


e         J>  e 

Fig.  6. — Section  through  the  Uvula  in  Diphtheritis  Faucium.  (Aniline-brown  staining; 
X  75.)  a,  normal  epithelium;  6,  normal  areolar  tissue;  c,  necrosed  epithelium  transformed 
into  a  coarse  mesh-work;  d,  areolar  tissue  infiltrated  with  fibrin  and  leucocytes;  e,  blood- 
vessels; /.  haemorrhage;  g,  heaps  of  micrococci. 

then  pass  into  a  peculiar  condition  of  rigidity  akin  to  coagula- 
tion. The  seat  of  this  change  appears  to  the  naked  eye  as  a 
dull  grayish  raised  patch  surrounded  by  red  and  swollen  mucous 
membrane.  The  exudation  is  rich  in  albumen  and  the  trans- 
formed cells  take  on  the  appearance  of  a  kind  of  coarse  mesh- 
work  almost  or  altogether  devoid  of  nuclei.  The  sub-epithelial 
areolar  tissue  is  beset  with  filaments  of  fibrin  and  leucocytes. 
Haemorrhages  are  not  uncommon.  Inflammations  of  this 
kind,  in  which  the  tissue  itself  coagulates  into  a  solid  mass,  are 
called  diphtheritic.     When  the  necrosis  and  coagulation  extend 


PATHOLOGY.  51 

only  to  the  epithelium  we  may  speak  of  the  process  as  super- 
ficial diphtheritis.  It  is  by  no  means  necessary "  either  in 
croupous  or  in  diphtheritic  inflammation,  "  that  the  whole  of 
the  epithelium  should  perish  at  the  outset;  some  part  of  ib  at 
least  may  perish  secondarily  in  consequence  of  the  inflamma- 
tion." 

The  anatomical  and  histological  distinction  between  the 
croupous  and  the  most  superficial  form  of  diphtheritic  false 
membrane  is,  therefore,  that  the  former  consists  mainly  of 
coagulated  fibrin  and  lies  superficially  over  the  epithelial  cells 
(sometimes  among  or  beneath  them)  being  connected  to  the 
mucous  membrane  only  by  filamentous  attachments  which  are 
easily  broken ;  while  the  latter,  even  when  superficial  and  thin, 
consists  mainly  of  transformed  epithelium  which  remains  in 
close  apposition  to  the  inflamed  living  tissues  beneath  it,  so  that 
if  it  be  torn  from  them  or  destroyed  by  chemical  agents  a  raw 
and  bleeding  surface  is  exposed. 

"  Deep  or  parenchymatous  diphtheria  is  characterized  by 
the  coagulation,  not  merely  of  the  epithelium  but  also  of  the 
underlying  connective  tissue.  The  epithelium  in  some  cases  is 
lost  altogether,  and  then  the  diphtheritic  patch  consists  of 
dead  connective  tissue  only.  The  patch  is  turbid  and  granular 
in  texture,  or  it  may  be  homogeneous  or  composed  of  amor- 
phous hyaline  blocks.  The  nuclei  are  always  more  or  less  com- 
pletely lost.  The  small  vessels  which  permeate  the  patch  show 
signs  of  a  homogeneous  transformation  of  their  walls.  The 
dead  tissue  is  separated  from  the  living  by  a  zone  of  cellular 
infiltration.  Fibrinous  filaments  are  seen  here  and  there 
through  the  mass.  The  lymphatics  in  the  neighborhood  con- 
tain coagula  and  leucocytes."     (See  Fig.  7.) 

Oertel *  in  his  latest  work  presents  with  great  minuteness 
and  detail  the  results  of  his  researches  into  the  histological 
changes  which  occur  in  diphtheria.  These  consist  primarily 
and  essentially  in  a  characteristic  degenerative  metamorpho- 

'"Die  Pathogenese  der  Epideinischen  Diphtherie."    Leipzig,  1887. 


52 


diphtheria;  its  nature  and  treatment. 


sis  in  the  cells  and  the,ir  nuclei.  This  takes  place  especially  in 
the  cells  "  which  are  derived  from  the  white  blood  corpuscles, 
and  are  known  under  the  collective  name  of  leucocytes."  The 
nucleus  shows  signs  of  retrogressive  metamorphosis.  The 
nuclear  membrane  breaks  up;  the  nuclear  and  the  cellular 
substance  run  into  one  mass,  and  the  different  forms  of  chro- 
matin undergo  a  similar  change.  The  longer  this  process  has 
continued  the  fewer  are  the  colorable  fragments  Of  nucleus, 
vesicles,  granules,  etc.     The  nuclei  or  granules  exhibit  peculiar 


W 


Fig.  7. — Section  of  the  Uvula  in  a  Case  of  Diphtheritis  Faucium.  (The  epithelium  has 
been  shed  ;  aniline-brown  staining  ;  x  100)  a,  micrococci ;  6,  submucous  tissue  changed  into 
amorphous  blocks  ;  c,  extravasated  leucocytes  ;  d,  fibrinous  exudation  ;  e,  blood-vessels  ;  /, 
lymphatic  vessel  containing  cells  and  fibrin. 


forms,  as  if  ligatured  and  partially  divided  in  two ;  free  nuclear 
and  granular  vesicles  are  seen,  and  others  which  are  connected 
by  minute  threads.  The  protoplasm  and  the  nuclei  are  trans- 
formed into  a  homogeneous  fluid  and  finally  coagulating  sub- 
stance. 

Explanation  of  Figure  8.  —  Section  of  a  Diphtheritic  Pharyngeal  Mucous  Membrane. 
False  membrane  invade  1  by  typical  rod-shaped  bacteria.  Cells  in  different  stages  of  de- 
composition and  division.  Necrosis  of  these  cells  and  of  the  upper  layers  of  the  mucous 
membrane.  Advancement  of  normal  cells  from  the  deeper  layers,  a,  necrotic  zone;  b,  dis 
eased  zone;  c,  apparently  normal  tissue;  F.N.,  fibrinous  network;  B.Y.,  bacterial  vegeta- 
tions; K.B  ,  vesicular  nuclei  with  parietal  arrangement  of  colorable  nuclear  substance; 
Z.  K.,  granular  detritus;  8ch.,  mucous  membrane;  d.A.,  direct  division  of  the  nuclei,  as  if 
by  ligature,  ("Kernabschniirung'");  i.F.,  cells  with  indirect  nuclear  fragmentation— Poly- 
morphous nuclei;  L,  leucocytes  in  the  deeper  layers  of  the  mucosa  and  submucosa. 


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-The  Diphtheritic  Process  in  the  Mucous  Membrane  of  the  Pharynx  and  Uvula. 
(Oertel.)    [See  opposite  page  for  explanation  of  Figure.] 


5-4  diphtheria;  its  nature  and  treatment. 

This  change  is  not  a  purely  chemical  one,  but  is  also  the  re- 
sult of  the  action  of  the  serous  and  fibrogenous  lymph  which 
has  exuded  with  the  white  corpuscles  from  the  blood-vessels. 

The  coagulation  of  this  substance  upon  a  free  surface  or 
within  the  interstices  of  the  mucous  membrane  or  of  the  tis- 
sues beneath  it,  with  an  accompanying-  hyaline  metamorphosis 
of  cells,  vessels  and  tissue-fibres,  constitute  false  membrane,  as 
has  been  already  described. 

The  characteristic  cell-changes  referred  to  are  seen  not  only 
in  false  membranes  and  the  subjacent  tissues  in  every  situa- 
tion, but  also  wherever  the  diphtheritic  poison  has  penetrated, 
and  in  a  degree  proportioned  to  the  directness  and  intensity  of 
its  action — in  the  tonsils  and  the  lymphatic  glands,  and  less 
uniformly  and  typically  in  more  remote  organs,  as  the  stomach 
and  intestines,  the  heart,  the  spleen,  etc. 

The  absence  of  the  characteristic  lesions  in  the  lungs  is 
opposed  to  the  hypothesis  of  a  primary  infection  of  the  system 
through  those  organs. 

The  inauguration  and  extension  of  the  diphtheritic  process 
are  described  as  taking  place  in  the  following  manner :  The 
diphtheritic  virus  irritates  the  epithelium  and  the  uppermost 
layers  beneath  it,  occasioning  a  profuse  emigration  of  leuco- 
cytes. These  cells,  which  have  come  as  a  protection,  absorb 
the  virus  and  become  diseased,  undergoing  the  necrobiotic 
changes  which  have  just  been  described.  Cells  of  various  sizes 
press  forward  to  take  up  the  struggle  with  the  invading  poi- 
son— among  them  the  large  protoplasmic  cells  which  are  called 
phagocytes.  Thick  and  dense  layers  of  these  cells  form  far 
under  the  epithelium  and  fill  the  whole  mucosa,  many  of  which 
sho  w  great  alterations  in  their  nuclei.  These  have  undoubtedly 
taken  up  poison  during  or  soon  after  their  emigration  from 
the  blood-vessels,  and  have  become  diseased.  They  soon  fall 
into  a  state  of  necrobiosis,  and  the  result  of  these  multiple  ne- 
crobiotic processes  and  the  irritation  which  they  excite  is  the 
renewed  accumulation  of  fresh  cells,  which  in  turn  are  exposed 


PATHOLOGY.  55 

to  the  ever-increasing-  poison  and  are  destroyed  in  great  num- 
bers. The  formation  of  extensive  necrobiotic  masses  or  depots 
in  and  beneath  the  mucosa  is  the  result  of  these  occurrences. 

In  connection  with  the  morbid  appearances  which  accom- 
pany diphtheritic  inflammation  various  kinds  of  bacteria  have 
in  many  cases  been  observed  on  the  surface  of,  and  within,  the 
false  membranes  and  in  the  underlying  tissues  and  vessels,  as 
has  been  stated  in  the  chapter  on  etiology. 

The  inflammatory  processes  which  have  been  described  oc- 
cupy a  various  length  of  time  in  reaching  their  completion; 
the  croupous  sometimes  does  this  by  throwing  out  successive 
exudations,  which  produce  distinct  layers  in  the  resulting  false 
membrane.  This  membrane  gradually  becomes  macerated  and 
its  filamentous  attachments  to  the  mucous  membrane  weak- 
ened by  muco-purulent  secretion  beneath  and  around  it,  so 
that  it  becomes  detached  either  in  minute  or  larger  portions. 

The  diphtheritic  inflammation  may  terminate  quickly  with 
the  production  of  a  limited  and  superficial  necrotic  patch,  or  it 
may  persist  for  some  time,  causing  the  death  of  deeper  and 
deeper  portions  of  the  epithelial,  the  mucous  and  the  sub-mu- 
cous tissues,  the  interpenetrating  fibrinous  network  and  bands 
being  reinforced  by  repeated  vascular  exudations,  and  an  in- 
tense purulent  inflammation  being  excited  in  the  subjacent  and 
surrounding  tissues.  When  the  diphtheritic  process  has  ceased, 
the  patches  or  sloughs,  as  foreign  bodies,  keep  up  irritative  in- 
flammation beneath  and  around  them.  The  superficial  epithe- 
lial patches  thus  become  infiltrated  with  pus  and  disintegrated 
or  cast  off,  and  the  deeper  sloughs  are  more  tardily  detached 
by  suppuration  and  demarcative  ulceration.  In  the  former 
case  the  loss  of  epithelium  is  readily  made  good  by  the  multi- 
plication of  the  epithelial  cells  which  remain ;  in  the  latter  a 
cicatrix  results  which  in  time  becomes  covered  with  new  epi- 
thelium. 

In  some  cases  the  gangrenous  form  of  necrosis  is  substi- 
tuted for  the  diphtheritic  by  the  penetration  into  the  diseased 


5()  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

tissues  and  the  rapid  multiplication  in  them  of  the  bacteria  of 
putrefaction. 

Either  of  the  forms  of  inflammation  above  described  may 
occur  on  any  mucous  membrane.  This  fact  shows  that  the 
occurrence  of  either  is  sometimes  determined  by  the  nature 
and  intensity  of  its  exciting-  cause  independently  of  local  ana- 
tomical conditions.  Yet  as  a  general  rule  the  occurrence  of 
one  or  the  other  form  of  inflammation  is  decided  or  greatly  in- 
fluenced by  the  anatomical  peculiarities  of  the  mucous  mem- 
brane upon  which  it  is  developed. 

The  mucous  membrane  of  the  mouth,  the  pharynx  and  the 
oesophagus  is  covered  with  thick  pavement  epithelium  which 
lies  immediately  upon  the  connective  tissue  of  the  mucosa 
without  the  intervention  of  a  basement  membrane.  These 
conditions  seem  to  favor  the  limitation  in  area  of  pseudo-mem- 
branous inflammation  and  its  deep  penetration,  when  it  has 
once  gained  a  foothold,  rather  than  its  rapid  superficial  exten- 
sion and  the  throwing  out  of  exudations  upon  the  surface. 

The  epithelium  of  this  region,  when  in  a  healthy  state,  is 
probably  impermeable  by  bacteria.  An  exception  to  this  con- 
dition has  been  demonstrated  by  Ph.  Stohr,  in  the  case  of  the 
tonsils,  the  epithelia  of  which  show  minute  cracks  or  loop-holes 
through  which  round  cells  emigrate,  and  through  which,  pre- 
sumably, micro-org-anisms  may  find  entrance — a  fact  which 
may  in  part  explain  the  especial  receptivity  of  these  organs  to 
the  diphtheritic  infection. 

The  oro -pharyngeal  mucous  membrane  is  in  most  parts 
abundantly  supplied  with  blood-vessels  and  lymph-vessels,  the 
latter  of  which  empty  into  various  glands  in  the  neck  and 
face,  the  principal  exception  being  the  tonsils,  in  which  both  are 
comparatively  few.  This  peculiarity  again  may  explain  the 
fact  that  while  tonsillar  diphtheria  is  the  commonest  it  is  the 
least  productive  of  general  infection. 

The  mucous  membrane  of  the  nasal  passages,  except  in  the 
nostrils,  and  of  the  air  passages,  except  on  the  true  vocal,  cords 


PATHOLOGY.  57 

and  the  aryteno-epigiottic  fold,  is  covered  with  cylindrical  epi- 
thelium. This  is  separated  from  the  subepithelial  tissues  by  a 
basement  membrane  which  is  their  uppermost  layer.  These 
anatomical  conditions  favor  the  "  croupous "  form  of  inflam- 
mation. 

'"Croupous"  and  '•'diphtheritic"  inflammation,  as  above 
described,  do  not  always  result  from  infection,  but  may  be  the 
effect  of  a  variety  of  other  causes.  Among-  these  causes  are  in- 
juries from  chemical,  thermal  and  physical  agencies. 

In  Guy's  Hospital  Reports  for  1ST?  Dr.  Hilton  Fagge  re- 
ported eleven  cases  of  membranous  laryngitis,  with  or  with- 
out pharyngitis,  which  were  directly  caused  by  local  injury  to 
the  throat,  the  injuries  being  scalds  by  hot  water,  the  entrance 
of  a  foreign  body  into  the  trachea,  a  cut  throat,  and  trache- 
otomy for  various  conditions.  Dr.  Fagge  remarks  upon  these 
cases  *  that  "  they  negative  the  a  priori  argument  that  the 
mucous  membrane  of  the  air-passages  is  not  likely  under 
simple  (or  non-specific)  irritation  to  take  on  an  inflammatory 
process  attended  with  the  formation  of  false  membrane." 

In  the  report  last  referred  to  (page  95)  an  interesting  and 
instructive  case  is  related  which  was  communicated  by  Dr. 
Whitehead  Reid.  In  the  application  of  a  bottle  of  eau-de-Co- 
logne to  the  nostrils  of  a  lady  who  had  fainted,  a  portion  of  the 
liquid  flowed  through  her  left  nostril  into  her  throat.  Symptoms 
of  intense  pharyngeal,  nasal  and  laryng-eal  inflammation  im- 
mediately followed.  On  the  third  day  false  membrane  ap- 
peared in  the  pharjmx  and  the  left  nostril.  Pieces  of  mem- 
brane were  several  times  coughed  up.  At  length  on  the  fifth 
day  a  perfect  cast  of  the  larynx,  the  trachea  and  the  upper 
part  of  the  left  bronchus,  was  expelled  entire  with  immediate 
relief  to  the  vocal  and  respiratory  symptoms,  and  the  temper- 
ature soon  fell  below  the  normal.  Small  pieces  of  membrane 
continued  to  be  coughed  up,  and  membrane  remained  in  the 

1  Report  of  Committee  of  the  Royal  Med.  and  Chirurg.  Society,  1878, 
on  the  relations  of  Membranous  Croup  and  Diphtheria. 


58  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

left  nostril  until  the  seventh  day.  The  lady  subsequently  made 
a  complete  recovery.  There  was  never  any  albumen  in  the 
urine;  no  paralysis  followed.  She  had  been  exposed  to  no 
scarlatinal  or  other  poison.  There  was  no  diphtheria  in  the 
village.  Neither  of  her  young*  children,  who  were  constantly 
with  her,  became  ill.  On  microscopic  examination  the  constit- 
uents of  the  expelled  cast  were  found  to  be  identical  with  those 
usually  found  in  croupous  pseudo-membrane  occurring- in  those 
localities. 

Many  instances  are  on  record  of  the  production  of  croup- 
membrane  in  the  throats  and  air-passages  of  horses  and  cattle 
by  their  inhaling  smoke  and  heated  air  in  burning  stables. 

Pseudo-membrane  has  been  artificially  produced  in  the 
trachea  of  animals  by  many  experimenters  by  the  application 
of  various  chemical  irritants;  by  Bretonneau  by  means  of 
tincture  of  cantharides  and  olive-oil,  and  subsequently  by  Tren- 
delenberg,  Oertel,Wood  and  Formad,Weigert  and  many  others 
by  the  application  of  ammonia,  corrosive  sublimate,  arsenic^ 
chlorine,  carbolic  acid,  etc.  The  pseudo-membranes  thus  pro- 
duced have  been  found  by  most  of  the  investigators  referred 
to  to  be  identical  in  all  discoverable  physical  and  chemical 
particulars  with  those  ordinarily  occurring  in  disease. 

Dr.  O.  Heubner,1  following  the  discovery  of  Cohnheim  and 
Litten,  that  coagulative  necrosis  may  be  produced  in  a  portion 
of  mucous  membrane  by  temporarily  cutting  off  its  blood- 
supply,  selected  as  the  most  suitable  one  for  his  experiments, 
for  anatomical  reasons,  that  of  the  fundus  of  the  urinary  blad- 
der of  the  rabbit.  By  ligating-  the  neck  of  the  organ  the  cir- 
culation was  completely  arrested.  The  ligature  was  removed 
after  two  hours,  when  the  circulation  was  restored  in  those 
vessels  which  were  free  from  thrombi.  The  result  of  the  oper- 
ation was,  first,  a  swollen  hemorrhagic  oedematous  condition 
of  the  mucous  'membrane,  the  epithelium  being  loosened  and 
its  more  superficial  layers  enlarged;  and  by  the  second  and 
1  Die  Experinientelle  Diphtherie.    Leipzig,  1883. 


PATHOLOGY.  59 

third  day,  in  patches,  a  necrotic  transformation  of  the  epithe- 
lium, the  mucous  membrane  and  the  submucous  tissues  into  a 
firm  yellowish  layer  which  was  morphologically  identical  with 
true  diphtheritic  membrane.  The  steps  in  this  process  are, 
first,  necrotic  changes  in  the  cells  and  other  constituents  of  the 
tissues,  including-  lesions  in  the  walls  of  the  blood-vessels  from 
inanition  during  the  interruption  of  their  blood-supply ;  second, 
the  current  being"  restored,  inflammatory  exudation  through 
the  dead  and  dying  tissues,  the  result  of  the  vascular  lesions, 
the  diphtheritic  process  being  thus  seen  to  be  a  nicely  adjusted 
combination  of  necrosis  and  inflammation,  in  which  the  tissue 
elements  must  be  dead  or  in  process  of  dying,  and  the  blood- 
vessels also  injured  but  not  yet  dead  or  occluded. 

The  process  of  pseudo-membranous  formation  resulting 
from  either  of  the  causes  just  referred  to  seems  to  be  an  en- 
tirely local  disease,  and  neither  accompanied  with  constitu- 
tional poisoning  nor  communicable  to  others.  Heubner  found 
his  diphtheritic  products  uninhabited  by  any  bacteria  except 
accidental  ones,  and  they  were  inoculated  into  other  animals 
without  result. 

The  facts  just  referred  to  have  an  obvious  bearing  on  the 
mooted  question  of  the  identity  or  diversity  of  membranous 
croup  and  diphtheria,  or,  more  precisely  stated,  the  question 
whether  all  cases  of  membranous  croup  are  cases  of  diphthe- 
ria. They  place  it  beyond  doubt  that  pseudo-membranous 
croup,  in  the  histological  and  anatomical  sense  of  the  term,  is 
a  condition  which  may  be  excited  by  a  variety  of  causes,  of 
which  diphtheritic  infection  is  only  one. 

In  the  clinical  sense,  however,  as  described  by  many  author- 
ities, simple  membranous  croup  is  a  non-infectious  phlegmasia 
of  the  laryngeal  or  the  laryngotracheal  mucous  membrane, 
and  is  the  result  of  meteorological  conditions,  which  act  upon 
it  either  as  direct  irritants  or  indirectly  through  the  organism 
by  the  series  of  reflexes  known  as  "catching*  cold."  By  far 
the  more  usual  effect  of  this  class  of  causes  upon  the  mucous 


60  diphtheria;  its  nature  and  treatment. 

membranes  is  the  production  of  catarrhal  inflammation.  That 
they  should  excite  instead  croupous  inflammation  in  excep- 
tional instances  is  explained  by  the  supposed  especial  inten- 
sity of  the  irritation  produced  in  those  cases  and  by  individual 
predisposition. 

Testimony  to  the  effect  that  not  a  few  cases  of  pseudo- 
membranous laryngitis  have  occurred,  which  were  in  no  way 
traceable  to  diphtheritic  or  other  infection,  and  followed  ex- 
posure to  cold,  to  cold  and  dampness,  to  sudden  changes  of 
temperature  or  to  cold  winds,  which  were  accompanied  with 
no  evidence  of  constitutional  diphtheritic  poisoning  nor  com- 
municated contagion  to  others,  abounds  in  medical  literature 
since  the  time  of  Home.  Much  of  it,  when  examined  by  the 
light  of  our  present  knowledge  of  the  diseases  in  question, 
must  be  rejected;  but  not  a  little  remains  which  is  so  precise 
in  character  and  from  such  competent  sources  that  it  cannot 
reasonably  be  doubted. 

Statistics  seem  to  show  a  much  more  direct  etiological 
relation  between  meterological  conditions  and  membranous 
croup  than  between  them  and  diphtheria.  In  a  large  aggre- 
gate of  fatal  cases  of  membranous  croup  collected  by  Hirsch1 
the  number  occurring  between  October  and  March  is  to  those 
occurring  in  the  warmer  half  of  the  year  nearly  as  two  to  one 
— a  much  larger  ratio  than  that  in  the  case  of  diphtheria,  as 
shown  in  the  chapter  on  etiology.  The  gross  inaccuracy  of 
the  nosological  classification  in  most  such  statistics  must  be 
conceded;  but  the  difference  referred  to  Avould  probably  be 
greater  rather  than  less  were  they  more  accurate. 

From  the  opposite  point  of  view  it  is  argued  that  some  ap- 
parently typical  cases  of  membranous  croup  prove  to  be  cases 
of  diphtheria  by  developing  in  their  later  stage,  if  they  last 
long  enough,  the  constitutional  symptoms  of  diphtheria,  and 
that  others  have  been  followed  by  cases  of  unquestionable 
diphtheria  which  were  evidently  due  to  their  contagion;  that 

'Op.  cit.,  p.  62. 


PATHOLOGY.  61 

the  absence  of  diphtheritic  constitutional  poisoning  in  other 
cases  may  be  due  to  their  short  duration  before  death  is  caused 
by  asphyxia,  and  also  to  the  fact  that  for  anatomical  reasons 
absorption  of  poison  takes  place  much  less  readily  from  "  croup- 
ous "  inflammation  in  the  larynx  and  trachea  than  from  diph- 
theria in  the  pharynx  or  nares;  that  membranous  laryngitis  is 
of  very  frequent  occurrence  in  connection  with  diphtheria,  and 
is  sometimes  its  initial  manifestation,  and  that  apparently 
typical  cases  of  membranous  croup  occur  with  especial  fre- 
quency in  some  epidemics  of  diphtheria. 

The  truth  of  all  these  statements  and  their  force  as  argu- 
ments are  unquestionable;  yet  it  seems  very  doubtful  if  they 
can  be  made  to  apply  to  or  to  explain  all  of  the  cases  originally 
referred  to.  Moreover,  it  seems  a  very  probable  supposition 
that  a  particular  case  of  disease,  occurring  in  places  in  which 
diphtheria  is  endemic  or  epidemic,  or  in  which  septic  influences 
are  present,  may  begin  as  a  local  non-infectious  membranous 
croup  and  subsequently  become  infected  by  those  agencies  and 
thus  converted  into  true  diphtheria,  since  croupous  inflamma- 
tion must  furnish  an  especially  favorable  soil  for  such  infection. 
Again,  the  view  that  there  is  a  membranous  croup  which  is  not 
due  to  diphtheria  is  strongly  favored  by  the  occurrence  of  the 
rare  analogous  affection,  idiopathic,  fibrinous  or  croupous 
bronchitis,  which  seems  to  be  due  to  the  causes  of  catarrhal 
bronchitis,  plus  an  individual  predisposition,  and  cannot  be 
supposed  to  be,  in  all  cases  at  least,  a  form  of  diphtheria. 

Virchow,  in  1885,  restated  to  the  Berlin  Medical  Society 
that  he  had  never  been  able  to  admit  that  all  cases  of  fibri- 
nous laryngitis  and  tracheitis  were  due  to  diphtheritic  poison. 

A  final  answer  to  the  question  under  consideration  can  only 
be  the  result  of  a  fuller  knowledge  than  we  at  present  possess; 
but  the  facts  which  we  have  seem  to  me  to  establish  a  basis  of 
strong  probability  for  the  following  conclusions :  Membranous 
croup,  as  above  described,  and  diphtheria  are  two  distinct 
affections.     Simple  membranous  croup  is  a  comparatively  rare 


62  DIPHTHERIA;    ITS    NATURE    AND    TREATMENT. 

form  of  disease.  In  regions  in  which  diphtheria  is  endemic  or 
epidemic  the  two  affections  are  so  liable  to  he  inter-complicated 
or  confounded  that  the  distinction  is  practically  valueless. 

In  following-  the  progress  of  diphtheria  from  local  to  gen- 
eral we  have  to  note  first  the  evidences  of  the  entrance  of  poi- 
son from  the  seat  of  the  local  affection  into  the  lymphatic  and 
vascular  systems.  Penetrating  the  lymphatic  vessels  to  the 
lymphatic  glands,  it  produces  inflammation  in  them,  and  this 
inflammation  is  to  he  observed  in  the  glands  which  are  thus 
directly  connected  with  the  part  primarily  affected.  The 
glands  are  affected  in  various  degrees,  from  a  slight  enlarge- 
ment to  an  intense  inflammation  of  the  glandular  structures 
themselves,  and  of  the  peri-glandular  connective  tissue.  They 
are  found  on  examination  to  he  in  a  state  of  vascular  engorge- 
ment and  cellular  hyperplasia,  and  the  surrounding  tissues 
cedematous  and  infiltrated  with  pus  cells  and  occasional  extrav- 
asations of  blood. 

The  absorption  of  poison  occurs  mainly  through  the  lym- 
phatics, but  evidently  in  some  cases  takes  place  through  the 
capillary  blood-vessels,  as  is  evidenced  by  the  fact  that  tox- 
aemia is  occasionally  rapidly  developed  when  there  is  little  or 
no  adenitis. 

,  The  blood  is  changed  in  color  and  in  consistency  in  a  con- 
siderable proportion  of  fatal  cases.  The  cause  and  nature  of 
these  changes  are  not  fully  known.  In  a  majority  of  instances 
the  change  is  to  a  darker  color  and  more  fluid  consistency 
than  in  health;  in  a  smaller  number  it  is  to  a  brownish  color 
and  a  turbid  condition,  in  which  it  communicates  a  stain  like 
sepia.  After  death  from  asphyxia  the  dark  color  may  be  due 
to  an  excess  of  carbonic  acid.  When  it  is  the  result  of  tox- 
aemia it  has  been  attributed  in  part  to  the  debris  of  the  disin- 
tegrated red  corpuscles.  A  marked  increase  in  the  number  of 
white  corpuscles  has  been  observed  in  some  cases.  There  is 
also  in  the  general  disintegration  of  the  constituents  of  the 
blood  a  diminution  in  the  amount  of  fibrin. 


PATHOLOGY.  63 

Coagula  are  found  in  the  cavities  of  the  heart  in  many 
cases.  These  differ  in  form,  size,  structure,  color  and  position. 
Some  are  said  to  have  in  these  respects  the  distinguishing 
characteristics  of  ante-mortem  clots. 

Dr.  Beverley  Robinson,1  as  a  result  of  many  careful  obser- 
vations, regards  these  formations  as  a  frequent  cause  of  death. 
His  observations  are  corroborated  by  others,  as  by  W.  C. 
ChafFey,  M.B.,2  who  states  that  in  twenty-three  post-mortem 
examinations  in  diphtheritic  cases  made  during-  the  previous 
two  and  one  half  years  at  the  Children's  Hospital  in  Great 
Ormond  Street,  London,  more  than  one  half  showed  marked 
fibrinous  deposits,  "probably  all  ante-mortem."  The  great 
majority  of  authorities,  however,  including  Cornil  and  Ran- 
vier,3  Sanne,4  Cadet  de  Gassicourt,5  and  A.  L.  Loomis 6  believe 
that  these  coagula  are  not  peculiar  to  diphtheria,  but  are 
formed  under  very  various  circumstances  during  the  death 
agony,  and  are  the  effect  rather  than  the  cause  of  the  cessa- 
tion of  cardiac  action. 

Coagula  are  also  found  in  the  large  veins  and  sinuses. 
Hemorrhagic  infarctions,  the  result  of  emboli,  occur  in  many 
situations — in  the  subcutaneous  connective  tissue,  beneath  the 
pericardium,  and  in  the  muscular  tissue  of  the  heart,  in  the 
lungs,  etc.  Venous  thromboses  are  seen  in  the  substance  of 
the  brain  and  its  investments,  the  liver,  the  spleen  and  other 
organs. 

The  heart  is  often  healthy  in  appearance,  but  in  some  cases 
important  changes  are  observed.  Among  these  are  the  effects 
of  myocarditis.  The  muscular  fibres  are  found  to  have  under- 
gone granulo-fatty  degeneration,  and  to  have  become  of  softish 
consistency  and  of  a  light  brownish  or  grayish  color,  and  to 

'"Thdsede  Paris,"  1872. 

2  British  Medical  Journal,  July  16,  1887,  p.  121. 

3 "  Manuel  d'histologie  pathologique. " 

4  Op.  cit.,  p.  105. 

6 "Maladies  de  l'Enfanee,"  t.  iii. 

6  Medical  News,  Nov.  10,  1888,  p.  539. 


6-i  diphtheria;  its  nature  and  treatment. 

contain  scattered  extravasations  of  blood.  These  changes 
niay  be  general  or  may  be  limited  to  a  few  fibres,  and  may 
occur  in  any  portion  of  the  heart-walls  or  in  the  columnar  car- 
neae.  Their  effect  is,  in  proportion  to  their  extent  and  their 
degree  of  advancement,  to  produce  dilatation  and  weakness  of 
the  heart. 

Endocarditis  occurs  in  some  cases  of  diphtheria  as  of  other 
acute  infectious  diseases,  but  is  not  a  frequent  complication. 
It  results  in  vegetations  and  fibrinous  deposits  on  the  valves, 
especially  the  upper  surface  of  the  mitral  valve.  These  are 
easily  detached  and  may  become  the  sources  of  the  widely  dis- 
tributed emboli  already  referred  to. 

The  lungs  are  subject  in  diphtheria  to  a  great  variety  of 
changes.  These  are  mostly  observed,  however,  in  those  cases 
in  which  death  has  resulted  from  croupal  asphyxia.  Among 
the  morbid  conditions  which  are  most  frequently  met  with  are 
simple  and  pseudo-membranous  bronchitis,  broncho-pneumo- 
nia, pulmonary  congestion  and  emphysema;  more  rarely  lobar 
pneumonia,  pulmonary  cedema,  pulmonary  apoplexy,  pulmo- 
nary gangrene. 

Catarrhal  bronchitis  is  in  the  majority  of  cases  the  accom- 
paniment of  laryngeal  diphtheria,  but  is  not  infrequently  as- 
sociated with  the  pharyngeal  and  nasal  forms. 

Pseudo-membranous  bronchitis  in  diphtheria  is  in  nearly 
all  cases  the  extension  downward  of  the  laryngotracheal 
affection,  though  in  rare  instances  the  bronchial  tubes  alone 
are  affected. 

Broncho-pneumonia,  in  its  various  forms  and  degrees,  is  of 
very  great  frequency  in  the  laryngeal  form  of  diphtheria, 
and  is  especially  common  in  connection  with  bronchial  diph- 
theria. 

Pulmonary  congestion  is  also  very  common  in  connection 
with  laryngeal  diphtheria,  usually  occupying  the  lower  and 
posterior  portion  of  one  or  both  lungs;  the  upper  and  anterior 
portions  are  as  frequently  emphysematous. 


PATHOLOGY.  65 

The  liver  is  usually  unaltered,  but  is  occasionally  en- 
larged and  congested  or  affected  with  waxy  or  fatty  degen- 
eration. 

The  spleen  is  usually  normal,  but  may  also  be  enlarged  and 

softened. 

The  kidneys  are  the  seat  of  the  most  frequent  and  important 
secondary  changes  occurring  in  diphtheria,  but  these  changes 
are  not  peculiar  or  characteristic.  The  kidneys  are  affected 
in  most  cases  which  terminate  fatally  from  systemic  poisoning; 
and  they  exhibit  every  degree  of  affection  from  a  slight  hyper- 
emia to  the  most  intense  inflammation.  The  most  usual  form 
of  nephritis  in  diphtheria  is  the  parenchymatous,  but  -the  inter- 
stitial is  not  infrequent. 

The  brain,  in  cases  in  which  death  has  resulted  from  croup, 
exhibits  venous .  engorgement  in  its  substance  and  its  mem- 
branes and  extravasations  of  blood— the  results  of  asphyxia. 
Serous  effusions  of  the  meninges  and  into  the  ventricles,  pus 
and  lymph  on  the  arachnoid  membrane,  or  a  granular  condi- 
tion of  the  white  substance  of  the  brain,  have  been  observed  in 
cases  in  which  there  had  been  grave  septicaemia  and  albumi- 
nuria with  cerebral  symptoms. 

In  some  observations  after  death  from  diphtheritic  paraly- 
sis, no  appreciable  changes  in  the  nervous  system  have  been 
discovered.  In  some  cases  there  have  been  various  degrees 
of  hyperasmia  in  the  brain  and  spinal  cord,  with  minute 
extravasations  of  blood,  or  in  rare  instances  larger  ones  into 
their  substance,  and  in  some  cases  meningeal  congestion  with 
or  without  hemorrhages  about  the  nerve  roots. 

The  lesions  which  are  characteristic  of  diphtheritic  paraly- 
sis are  only  revealed  by  the  microscope,  and  are  found  in  the 
peripheral  nerves  which  supply  the  parts  affected,  in  the  gray 
matter  of  the  anterior  cornua  of  the  spinal  cord,  and  in  severe 
cases  of  long  duration  in  muscular  fibres,  especially  in  the  soft 
palate,  but  occasionally  in  the  extremities. 

The  peripheral  lesions  were  first  observed  by  Charcot  and 


66  DIPHTHERIA;    ITS   NATURE    AND    TREATMENT. 

Vulpian *  in  a  case  of  paralysis  of  the  velum  palati.  Some  of 
the  muscular  fibres  in  that  organ  were  in  a  state  of  fatty  de- 
generation. In  the  muscular  nerves  some  of  the  fibres  con- 
sisted of  tubules  emptied  of  their  medullary  substance.  The 
neurilemma  contained  in  some  places  numerous  granular  bodies 
with  or  without  nuclei.  Lorain  and  Lepine  found  similar 
changes  in  the  soft  palate,  and  Liouville  in  the  phrenic  nerves. 
Buhl2  in  one  case  found  hemorrhages  in  the  cerebral  pia  mater 
and  cortex,  infarcts  in  many  parts  of  the  brain  and  spinal  cord, 
and  the  spinal  ganglia  and  nerve-roots  swollen,  the  swelling 
being  due  to  infiltration  of  the  nerve  sheaths  and  the  intersti- 
tial tissue  with  nuclear  bodies  which  he  considered  character- 
istic of  diphtheritic  inflammation.  Leyden  found  in  one  case 
appearances  of  a  "neuritis  migrans "  ascending  toward  the 
nerve  centres  as  far  as  the  medulla  oblongata ;  Oertel 3  in  one 
case  multiplication  of  nuclei  in  the  gray  substance  of  the  spinal 
cord,  especially  in  the  anterior  cornua,  and  hemorrhagic  patches 
in  the  cord  and  pia  mater;  Vulpian4  in  three  cases  "rarefac- 
tion "  of  connective  tissue  in  the  anterior  horns,  with  altera- 
tions in  the  motor  nerve-cells  and  slight  increase  in  the  number 
of  nuclei  in  the  spinal  cord ;  Pierret 5  in  one  case  disseminated 
patches  of  spinal  meningitis  with  peri-neuritis  of  nerve-roots. 
Dejerine6  found  in  five  cases  constant  changes  in  the  ante- 
rior cornua  with  consecutive  neuritis  of  the  corresponding  an- 
terior spinal  nerve-roots.  The  affected  nerve  cells  were  swollen 
in  some  instances,  in  others  shrunken,  were  indistinct,  had  lost 
their  processes  and  were  globular  in  shape.  The  number  of 
nerve -cells  in  certain  portions  of  the  anterior  cornua  was  di- 
minished. The  small  vessels  were  distended  with  blood  and 
dilated,  and  hemorrhages  from  their  rupture  were  observed  in 

'Compt.  rend,  de  la  Soc.  de  Biol:,  1862. 

2Zeitsch.  f.  Biol.,  1867. 

aDeutsches  Arch.  f.  Klin.  Med.,  viii.,  1871. 

4  Malad  de  Syst.  Nerv. ,  1870. 

6Compt.  rend,  de  la  Soc.  de  Biol.,  1876. 

6  Arch,  de  Phys.  norm,  et  path.,  t.  v.,  p.  107,  1878. 


PATHOLOGY.  67 

the  anterior  cornua  together  with  perivascular  collections  of 
small  cells.  Around  the  central  canal  there  was  cell-infiltra- 
tion of  an  inflammatory  nature.  Dejerine  regarded  this  affec- 
tion of  the  spinal  cord  as  subacute  tephro -myelitis,  the  accom- 
panying neuritis  of  the  anterior  spinal  roots  being'  secondary 
to  the  spinal  lesion. 

Gaucher 1  in  one  case  found  changes  in  the  anterior  cornua 
and  nerve-roots  identical  with  those  described  by  Dejerine. 
Abercrombie 2  in  seven  cases,  Percy  Kidd  3  in  one  case,  and  Dr. 
Mott  of  Liverpool,  as  reported  by  Percy  Kidd,  in  one  case,  in 
which  only  the  brain  and  spinal  cord  were  examined,  also 
found  similar  lesions  in  the  latter  to  those  described  by  Dejer- 
ine. Meyer  4  in  one  case  found  inflammatory  changes  in  the 
gray  matter  of  the  anterior  and  posterior  cornua  of  the  spinal 
cord,  degeneration  of  spinal  roots  and  neuritis  in  phrenic  and 
muscular  nerves.  Pitres 5  in  one  case  found  parenchymatous 
neuritis  of  the  peripheral  nerves  and  spinal  roots  with  no 
alteration  in  the  spinal  cord.  Mendel 6  in  one  case  found  marked 
congestion  of  small  arteries  of  the  brain;  capillary  hemor- 
rhages in  pons,  medulla,  and  near  the  nucleus  of  the  oculo-motor 
nerve;  neuritis  of  peripheral  nerves,  especially  the  oculo- 
motor, abducens,  and  vagus. 

1  Journ.  de  Tana/tom.  de  Robin,  1881. 

2  Trans.  Internat.  Med.  Cong.,  1881. 

3 Med.  Chir.  Trans.,  lxvi.,  1885,  p.  136. 
4Virch.  Archiv.,  vol.  lxxxv.,  p.  181. 
5Areb.  de.  Neurol.,  1886,  xi.,  p.  337. 
6  Berliner  Klin.  Woehenschr.,  12,  1885. 


CHAPTER  IV. 

SYMPTOMS. 

Diphtheria  is  classed  according  to  its  localization  as 
pharyngeal,  nasal,  laryngeal,  ocular,  vulvar,  cutaneous,  etc. 

According  to  its  intensity,  as  mild,  severe  and  malignant. 

According  to  the  degree  of  toxic  absorption,  as  benign  and 
septic. 

According  as  it  is  idiopathic  or  supervenes  upon  other  dis- 
eases, as  primary  or  secondary. 

Diphtheria  has  many  complications.  These  may  be  mainly 
due  either  to  the  mechanical  interference  of  the  false  mem- 
brane with  respiration;  as  is  seen  in  certain  pulmonary  com- 
plications of  diphtheritic  croup,  or  to  hsemic  poisoning,  as  is 
seen  in  the  morbid  affections  of  the  kidneys,  the  heart  and  other 
organs. 

Diphtheria  has  also  certain  sequelae,  the  most  important 
and  characteristic  of  which  is  paralysis. 

Diphtheria  of  the  Pharynx  and  Soft  Palate. 

The  pharynx  is  by  far  the  most  usual  site  of  diphtheritic 
inflammation.  Not  only  are  a  large  majority  of  all  diphthe- 
ritic attacks  limited  to  this  locality,  but  in  a  great  proportion 
of  all  cases  in  which  the  larynx,  the  nasal  passages  or  the 
mouth  are  invaded,  the  pharynx  is  also  affected  either  prima- 
rily or  secondarily. 

No  portion  of  the  pharynx  is  so  often  affected  as  the  tonsils. 
In  thirty-eight  cases  accurately  described  by  me,1  the  location 

1  New  York  Med.  Record,  March  27th,  1880,  p.  340. 


SYMPTOMS.  69 

of  diphtheritic  membrane  was  as  follows:  tonsils  only,  11;  ton- 
sils and  velum  palati,  3;  tonsils  and  nares,  4;  tonsils,  soft  pal- 
ate and  nares,  8 ;  tonsils  and  tongue,  1 ;  tonsils,  nares,  uvula 
and  gums,  1 ;  tonsils,  nares,  soft  palate  and  tongue,  1 ;  tonsils, 
nares,  soft  palate,  tong-ue  and  lips,  1;  tonsils  and  larynx,  1; 
tonsils,  soft  palate  and  larynx,  4 ;  uvula,  1 ;  velum,  1 ;  uvula 
and  nares,  1 ;  showing  the  tonsils  to  have  been  affected  in 
thirty-five  out  of  thirty-eight  cases.  From  my  observation  of 
much  larger  numbers  of  cases  of  which  my  records  are.  less 
complete,  I  think  that  this  distribution  is  about  an  average 
one,  except  that  in  some  epidemics  the  proportion  of  laryn- 
geal cases  would  be  much  greater. 

The  Catarrhal  Stage. 

The  symptoms  of  the  initial  stage  of  pharyngeal  diphtheria 
differ  in  no  respect  from  those  of  the  same  stage  of  other  forms 
of  sore  throat.  As  in  them,  there  may  be  for  a  period  varying 
from  a  few  hours  to  several  days  feelings  of  depression,  slight 
chilliness,  f everishness,  anorexia,  nausea,  headache,  slight  pains 
in  the  neck,  back  or  extremities.  A  pronounced  chill  is  less 
usual,  but  sometimes  occurs.  In  children  of  highly  suscepti- 
ble nervous  organization  there  may  be  convulsions. 

The  temperature  is  elevated  from  one  to  several  degrees, 
and  the  pulse  is  correspondingly  accelerated. 

At  this  stage  of  the  disease,  and  as  its  first  noticeable 
symptom,  there  are  often  pain  and  difficulty  in  swallowing, 
but  sometimes  there  is  an  entire  absence  of  subjective  throat 
symptoms. 

If  the  throat  be  inspected,  however,  it  will  invariably  be 
found  to  be  more  or  less  reddened  and  congested.  This  ap- 
pearance may  be  general,  but  more  usually  is  limited  or  un- 
equal, affecting  especially  one  tonsil  and  its  immediate  sur- 
roundings, or  one  of  the  faucial  arches  and  the  uvula,  or  a  well- 
defined  patch  on  the  anterior  surface  of  the  soft  palate. 


70  diphtheria;  its  nature  and  treatment. 

The  Stage  of  Pseudo-Membranous  Formation. 

The  transition  from  the  catarrhal  stage  to  the  croupous  or 
the  diphtheritic,  when  watched,  is  seen  to  consist  in  a  gradual 
deepening-  of  the  angry  redness  in  one  or  more  patches  of  the 
mucous  membrane,  and  then  the  appearance  upon  them  of  dots 
or  streaks  of  a  pearly  or  yellowish  whiteness.  These  multiply, 
extend  and  coalesce  over  the  affected  surface  until  it  is  covered 
with  a  smooth,  glistening  layer  ("  croupous "),  the  margin  of 
which  is  surrounded  with  a  red  or  purplish  ring.  Or  yellow- 
ish spots  appear  on  the  surface  of  the  mucous  membrane,  and 
then  become  more  and  more  definite  and  opaque,  until  their 
aggregation  assumes  the  appearance  of  a  patch  of  yellow  or 
gray  chamois  leather  imbedded  in  the  intensely  inflamed  tis- 
sues (" diphtheritic").  The  exudative  deposit  or  the  necrotic 
change  thus  occurring  may  soon  reach  its  completion,  with  a 
moderate  degree  of  surrounding  inflammation  and  febrile  dis- 
turbance, or  with  a  persistence  and  intensification  of  both  it 
may  continue  to  extend  by  an  enlargement  of  the  patches  al- 
ready formed,  or  the  appearance  of  additional  ones. 

The  pain  in  the  throat  is  sometimes  so  slight  that  the  real 
nature  of  the  ailment  is  unsuspected  until  it  is  revealed  by 
inspection ;  but  it  more  usually  varies  from  a  sense  of  stiffness 
or  pricking  to  a  most  acute  distress  on  swallowing. 

Vomiting  is  a  frequent  symptom,  and  at  this  stage  of  the 
disease  is  usually  a  reflex  from  the  faucial  irritation,  as  when 
the  throat  is  tickled  with  a  feather.  I  have  seen  it  to  be  par- 
ticularly liable  to  occur  when  the  uvula  is  the  seat  of  diphthe- 
ritic inflammation. 

The  throat  is  filled  with  mucus,  which,  at  first  white  and 
tenacious,  becomes  more  and  more  purulent  and  sometimes 
reddish  or  streaked  with  blood  from  hemorrhagic  points  in  the 
inflamed  mucous  membrane. 

Fcetor  in  the  breath,  slight  at  first,  becomes  more  and  more 
noticeable. 


SYMPTOMS.  71 

Adenitis  may  be  so  slight  as  to  be  scarcely  perceptible,  or 
may  rapidly  become  a  prominent  and  formidable  symptom. 

The  temperature  is  now  at  its  highest,  and  may  vary  from 
an  elevation  of  one  or  two  degrees  above  the  normal  to  105°  or 
106°  F.  It  is  usually  in  direct  proportion  to  the  intensity  of 
the  inflammation  in  the  mucous  membranes,  the  sub-mucous 
tissues  and  the  glands. 

The  acceleration  of  the  pulse  at  this  stage  of  the  disease  is 
usually  in  proportion  to  the  rise  in  temperature,  and  sometimes 
exceeds  that  proportion.  There  are  in  some  cases  other  quali- 
ties to  be  noted  besides  its  rapidity.  It  may  be  small,  thready, 
irregular  or  flickering.  This  is  usually  in  cases  in  which  there 
is  a  rapid  onset  of  throat  inflammation  and  adenitis,  with  acute 
faucial  pain  and  reflex  nausea  and  vomiting.  It  is  then  the 
pulse  of  shock.  The  abundant  nerve  supply  in  the  throat  causes 
it  to  be  the  source,  when  irritated,  of  various  remote  reflex  dis- 
turbances, and  these  may  include  the  action  of  the  heart.  This 
point  is  important,  because  this  quality  of  the  pulse  at  this 
stage  of  the  disease  is  often  attributed  to  the  essentially  weak- 
ening effect  of  diphtheria,  and  therefore  supposed  to  call  for 
early  and  profuse  stimulation.  That  this  is  not  usually  the 
case  is  proved  by  the  fact,  which  I  have  often  observed,  that 
after  the  extension  of  inflammation  has  ceased  and  the  attend- 
ing pain  and  nerve  disturbance  have  abated  the  pulse  returns 
to  nearly  its  normal  volume  and  regularity,  although  the 
process  of  constitutional  poisoning  peculiar  to  the  disease 
may  then  have  really  commenced  or  become  more  advanced 
than  before. 

The  character  of  the  disease  at  this  stage  is  usually  sthenic, 
though  some  of  its  symptoms  may,  as  has  just  been  pointed 
out,  apparently  indicate  asthenia.  Its  essential  feature  is  pro- 
gressive diphtheritic  inflammation.  Upon  the  extent  and  in- 
tensity of  this  inflammation  depend  not  only  the  accompan}7- 
ing  symptoms,  but  in  most  cases  the  subsequent  type  and 
gravity  of  the  malady. 


72  diphtheria;  its  nature  and  treatment. 

Mild  or  Benign  Form. — In  this  form  the  symptoms  which 
have  now  been  referred  to  are  relatively  moderate  in  degree 
and  transient  in  duration.  The  temperature  rarely  exceeds 
104°  F.;  adenitis  is  slight;  the  swelling  of  the  throat  is  not 
very  marked,  though  the  tonsils  may  he  considera  bly  enlarged. 
The  false  membrane  is  often  limited  to  the  tonsils,  though  it 
not  infrequently  covers  more  or  less  of  the  surface  of  the  fau- 
cial  pillars,  the  soft  palate  and  the  uvula.  Its  character  is  dis- 
tinctive, being  invariably  comparatively  superficial. 

Severe  Form. — In  this  form,  on  the  other  hand,  the  symp- 
toms are  usually  correspondingly  grave.  The  temperature 
may  reach  105°  or  106°  F.;  adenitis  is  commonly  quite  marked, 
and  may  be  very  great.  The  inflammation  in  the  throat  is 
more  intense  than  in  the  other  form,  the  swelling  being  greater, 
the  redness  of  the  mucous  membrane  deeper,  and  the  false 
membrane  usually,  though  not  necessarily,  more  extensive — 
sometimes  covering  the  entire  pharynx  and  soft  palate  in  one 
nearly  continuous  investment.  Its  character  is  also  distinct- 
ive. Some  portion  of  it,  at  least,  is  of  the  deep  or  parenchy- 
matous variety. 

Further  Course  of  the  Disease  and  its  Terminations. 

When  the  diphtheritic  inflammation  has  reached  its  acme 
— usually  from  the  second  to  the  fourth  day  of  the  disease — 
the  predominant  symptoms  undergo  a  change  in  two  respects : 
There  is,  first,  a  subsidence  of  the  febrile  symptoms  to  the 
milder  ones  of  a  subacute  inflammation  which  is  mainly  due 
to  lesions  already  produced;  and,  second,  the  first  appearance 
in  some  cases,  and  a  notable  increase  in  others  of  symptoms 
which  denote  constitutional  infection. 

Mild  or  Benign  Form. — This  has  two  modes  of  termina- 
tion. Usually  it  is  favorable.  The  faucial  inflammation  and 
the  fever  subside  and  do  not  return.  The  false  membrane  ex- 
foliates after  from  three  to  seven  days'  continuance,  when  the 
mucous  membrane  is  seen  to  be  only  slightly  hyperasmic,  and 


SYMPTOMS.  78 

soon  recovers  its  normal  appearance.  In  rarer  cases  the  dis- 
ease, after  continuing-  for  some  days  in  this  form,  suddenly, 
either  from  injudicious  treatment  or  exposure  to  cold,  or  some 
cause  which  is  not  so  obvious,  takes  on  a  new  aspect — the 
diphtheritic  inflammation  becoming-  not  only  more  extensive 
but  more  intense  and  deeper — and  assumes  the  form  next  to 
be  described. 

Severe  Form. — In  this  form  of  the  disease  the  more  super- 
ficial portions  of  the  false  membrane  may  exfoliate  in  a  few 
days  as  in  the  milder  form ;  but  the  deeper  portions,  sometimes 
very  extensive,  and  sometimes  only  a  single  limited  patch, 
continue  after  the  rest  has  disappeared,  impenetrable  to  ordi- 
nary antiseptic  remedies,  and  causing  far  greater  local  irrita- 
tion and  more  profound  constitutional  poisoning  than  that  has 
done. 

Nasal  and  oral  diphtheria  are  very  frequent  complications, 
and  add  materially  to  the  gravity  of  the  disease.  These  will 
therefore  now  be  described. 

Nasal  Diphtheria. 

Nasal  diphtheria  is  most  usually  secondary  to  pharyngeal 
diphtheria,  making  its  appearance  after  the  affection  in  the 
throat  has  existed  for  one  or  more  days;  yet  in  many  cases  it 
is  primary,  preceding  the  other  or  appearing  at  the  same  time 
with  it.  In  some  cases  the  disease  is  limited  to  the  nasal 
passages  throughout  its  course. 

When  the  affection  begins  too  high  up  for  the  false  mem- 
brane to  be  visible  on  inspection,  its  nature  may  be  for  a  time 
uncertain,  but  it  is  usually  soon  recognizable  by  the  degree 
of  obstruction  which  it  causes  and  by  the  character  of  the  dis- 
charge from  the  nostrils.  This  becomes  either  thin  and 
ichorous,  or  profuse,  yellowish  and  muco-purulent.  It  is  often 
very  irritating,  producing  excoriation  on  the  margins  of  the 
nostrils  and  the  upper  lip,  which  become  coated  with  diph- 


74  diphtheria;  its  nature  and  treatment. 

theritic  membrane.  There  is  also  quite  early  a  characteristic 
foetor. 

Epistaxis  often  occurs.  This  may  result  from  capillary 
congestion  or  commencing-  ulceration,  and  may  follow  picking 
or  rubbing-  the  nose  or  maladroitness  in  administering  injec- 
tions, etc.  It  is  then  usually  slight  or  easily  controllable. 
Later  it  may  result  from  more  extensive  ulceration  of  the 
mucous  membrane  or  from  a  hemorrhagic  tendency  conse- 
quent upon  the  constitutional  poisoning,  and  is  then  profuse, 
persistent  and  difficult  to  control.  I  have  never  known  of  its 
being  the  immediate  cause  of  death,  bat  the  serious  exsangui- 
nation  which  it  produces  when  the  system  is  already  anaemic 
and  enfeebled  is  doubtless  in  some  cases  the  determining  cause 
of  a  fatal  result. 

The  chief  importance  and  gravity  of  nasal  diphtheria,  how- 
ever, results  from  the  fact  that  it  is  especially  liable  to  be 
attended  with  constitutional  poisoning  by  absorption.  This 
results  from  two  causes :  first,  the  Schneiderian  membrane  is 
abundantly  supplied  with  absorbent  vessels  by  means  of  which 
the  poison  is  conveyed  into  the  general  circulation;  and  second, 
while  the  throat  is  washed  by  the  saliva  and  by  food  and  drink 
as  well  as  medicines  which  are  swallowed,  there  is  no  such 
provision  of  nature  for  the  disinfection  of  the  nasal  passages. 

As  a  result  of  this  toxic  absorption  adenitis  is  a  usual  ac- 
companiment of  nasal  diphtheria.  Yet  in  some  grave  cases 
adenitis  is  only  very  slight. 

I  have  already  stated  that  in  rare  cases  diphtheria  is  limited 
to  the  nasal  passages.  When  the  posterior  nares  only  are 
thus  affected  the  nature  of  the  disease  is  liable  to  be  over- 
looked. Its  presence  may  be  suspected  from  the  existence  of 
symptoms  of  diphtheritic  poisoning  with  those  of  post-nasal 
catarrh. 


symptoms.  75 

Diphtheria  of  the  Mouth. 

Diphtheria  of  the  mouth  is  usually  a  complication  of  pha- 
ryngeal diphtheria.  It  often  alights  on  points  where  abrasion 
of  the  epithelium  or  ulceration  exists.  In  a  case  in  which  a 
too  energetic  nurse  persisted,  in  spite  of  my  remonstrances,  in 
removing-  the  secretions  from  the  mouth  of  an  infant  suffering 
with  diphtheria  by  wiping  it  out  with  a  napkin,  diphtheritic 
patches  appeared  on  the  tongue  and  the  lips.  In  some  in- 
stances, however,  the  mouth  is  the  only  region  affected.  Its 
most  usual  situation  is  the  lips — either  the  angle  at  their  junc- 
tion or  the  inside  of  the  lower  lip.  In  such  cases  the  lip  some- 
times becomes  greatly  swollen.  Next  in  frequency  to  the  lip 
diphtheria  occurs  on  the  tongue.  In  that  situation  it  may 
be  superficial  and  of  transient  duration,  or  deep  and  persistent 
and  accompanied  with  great  swelling.  It  occurs  also  on  the 
gums  and  on  the  mucous  membrane  lining  the  cheeks.  In 
those  localities  also  it  may  be  of  very  various  degrees  of  depth, 
extent,  severity  and  persistency,  and  attended  with  various 
degrees  of  constitutional  poisoning. 

Constitutional  or  Septic  Diphtheria. 

In  the  form  of  diphtheria  now  under  consideration — namely, 
the  severe  form  of  pharyngeal  diphtheria  with  or  without  the 
complications  just  referred  to — constitutional  poisoning  in  a 
greater  or  less  degree  is  invariably  present,  and,  in  the  absence 
of  laryngeal  diphtheria,  is  the  chief  source  of  danger. 

Among  the  earliest  symptoms  of  this  condition  is  cachectic 
pallor,  the  flush  of  fever  being  gradually  replaced  by  an  ashen 
or  sallow  tinge.  The  eye  loses  its  brightness  and  the  expres- 
sion of  the  countenance  becomes  dull  and  apathetic.  There  is 
often  marked  drowsiness. 

The  impoverished  and  poisonous  blood-condition  reacts 
upon  the  local  inflammation  itself.     It  becomes  less  acute  and 


76  diphtheria;  its  nature  and  treatment. 

is  attended  with  less  pain.  If  it  continues  to  extend  it  does 
so  more  slowly  and  insidiously.  The  pseudo-membrane  loses 
its  smoothness  and  whiteness  and  becomes  sodden  in  appear- 
ance and  of  a  dingy  gray,  or  is  dark-colored  from  capillary 
haemorrhages  beneath  and  around  it.  The  mucous  membrane 
around  its  margin  becomes  paler  or  more  livid,  and  is  flaccid 
or  cedematous.  The  secretions  are  ichorous  or  sanious,  and 
very  foetid.  It  is  not  strange  that  the  symptoms  in  bad  cases 
should  have  impressed  the  earlier  observers  with  the  belief 
that  the  process  they  beheld  was  one  of  gangrenous  dis- 
organization. 

It  is  important  to  remark,  however,  that  grave  and  fatal 
poisoning  may  take  place  in  diphtheria  without  any  such 
striking  evidences  of  putrefactive  changes  in  the  throat.  The 
system  may  be  rapidly  infected  from  a  limited  diphtheritic 
area  in  the  nasal  passages,  or  from  beneath  a  small  and  ap- 
parently, trivial  membranous  patch  in  the  throat,  if  that  patch 
penetrates  the  mucous  membrane  and  its  under  surface  is  in 
relation  with  absorbent  vessels,  though  itself  may  remain  un- 
changed. The  view  presented  by  some  authorities,  that  the 
occurrence  of  septic  poisoning  in  diphtheria  depends  upon 
putrefactive  decomposition  of  diphtheritic  membrane,  is  a 
dangerous  error.  The  pseudo-membrane  is  rather  a  covering 
beneath  which  the  septic  processes  which  are  peculiar  to  the 
disease  may  go  on  undisturbed  and  their  products  may  ac- 
cumulate for  absorption  and  dissemination.  The  more  ad- 
vanced these  processes  are,  however,  and  the  more  abundant 
their  products,  the  greater  is,  of  course,  the  liability  to  such 
dissemination. 

All  the  symptoms  now  manifest  a  progressive  tendency  to 
asthenia.  The  fever  usually  gradually  abates.  The  temper- 
ature, as  a  rule,  declines  to  a  moderate  elevation  above  the 
normal,  or  sometimes  even  falls  to  97°  or  96|°  F.,  though  in 
exceptional  cases  lryperpyrexia  is  marked  and  persistent.  The 
pulse  becomes  weaker  and  is  often  irregular.     It  is  easily  dis- 


SYMPTOMS.  77 

turbed  by  any  slight  exertion  or  excitement.  Digestion  is 
feeble.  There  is  indifference  and  often  aversion  to  food  and 
drink,  and  if  they  are  forced  upon  the  patient  nausea  and 
vomiting'  result. 

In  this  form  of  diphtheria  there  is  almost  always  albumi- 
nuria, and  frequently  grave  implication  of  the  kidneys.  These 
will  be  separately  considered. 

Delirium  sometimes  occurs,  but  is  infrequent. 

When  this  form  of  the  disease  terminates  fatally  it  is 
usually  in  the  course  of  the  second  week — that  is,  from  the 
eighth  to  the  fourteenth  day.  Death  most  frequently  follows 
a  gradual  failure  of  the  vital  forces  caused  by  the  progressive 
impoverishment  and  poisoning  of  the  blood,  or,  in  other  words, 
results  from  exhaustion  and  asthenia.  The  most  notable  pre- 
ceding symptom  is  usually  the  progressive  weakness  of  the 
circulation  as  manifested  in  the  pulse  and  the  heart-sounds, 
pallor,  cold  clammy  perspirations,  coldness  of  the  extremities, 
etc.  Sometimes  there  is  a  rapid  development  of  the  signs  of 
pulmonary  oedema.  In  rare  instances  there  are  symptoms  of 
grave  cerebral  implication.  Quite  often  death  occurs  sud- 
denly and  more  or  less  unexpectedly  by  heart-failure  after 
some  slight  excitement  or  exertion — in  some  instances  after 
merely  sitting  up  in  bed — as  a  result  of  cardiac  paralysis  or 
the  weakening  of  the  heart  by  myocardial  degeneration. 
Death  oy  this  mode  takes  place  not  merely  during  the  contin- 
uance of  the  diphtheritic  affection,  but  in  some  instances 
weeks  after  its  cessation,  and  when  good  progress  has  been 
supposed  to  have  been  made  in  recovering  from  its  effects. 

When  recovery  takes  place  it  is  usually  slow  and  gradual 
in  proportion  to  the  degree  of  hsemic  impoverishment  and  dis- 
organization and  of  tissue  degeneration.  The  pseudo-mem- 
brane and  the  nasal  discharge  rarely  disappear  before  the 
tenth  or  twelfth  day  of  the  disease.  Even  before  that  event 
there  is  in  some  cases  a  mitigation  in  the  constitutional  symp- 
toms.    In  other  cases  they  continue  unabated  until  it  occurs 


78  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

and  then  improve  with  striking-  rapidity,  showing-  their  direct 
dependence  on  the  causes  just  referred  to. 

Sometimes  after  a  few  hours  or  a  day  or  two  of  such  im- 
provement there  is  a  return  of  febrile  symptoms,  and  the 
pseudo-membrane  which  has  nearly  or  quite  disappeared  is 
replaced  by  a  new  formation  accompanied  with  a  renewal  or 
intensification  of  the  toxaemia,  and  causing-  another  period  of 
anxiety  and  danger  lasting*  from  five  to  ten  days,  the  second 
formation  of  membrane  being-  seldom  quite  as  deep  or  persist- 
ent as  its  predecessor.  In  rare  cases,  when  the  patient  has 
survived  this  relapse,  it  is  followed  by  a  second  of  shorter  con- 
tinuance, so  that  the  whole  duration  of  membranous  disease 
is  from  three  to  four  weeks. 

In  occasional  instances  the  membranous  formation  is  white, 
not  very  tough  nor  very  deep  nor  very  thick,  but  evidently 
consists  of  a  transformation  of  the  superficial  epithelium,  or,  in 
other  words,  is  of  the  varietj'-  described  as  "  superficial  diph- 
theria." It  is  closely  adherent  to  the  mucous  membrane  and 
never  exfoliates  in  large  pieces.  It  is  often  located  on  the 
anterior  side  of  the  soft  palate,  or  around  the  uvula,  or  on  the 
posterior  side  of  the  soft  palate,  or  less  frequently  on  the  pos- 
terior wall  of  the  pharynx.  Without  ever  completely  disap- 
pearing- this  membranous  affection  sometimes  diminishes  and 
sometimes  extends,  with  only  moderate  inflammation  and 
fever,  but  with  marked  pallor,  cachexia  and  constitutional  de- 
pression, persisting-  altogether  from  two  to  four  weeks.  I 
have  seen  several  such  cases  in  children  and  two  in  adults, 
one  of  whom  was  seventy  years  of  age.  In  the  last  mentioned 
case  the  temperature  varied  between  96-f°  and  98°  F.  for  nine 
days,  being- usually  below  9r|°;  the  whole  duration  of  mem- 
branous disease  being  four  weeks.  All  these  cases  termi- 
nated favorably. 

In  many  cases  a  prolonged  and  critical  period  of  weakness 
follows  the  final  disappearance  of  the  membranous  affection. 
There  may  be  relaxation  and  catarrh  of  the  upper  air -pas- 


SYMPTOMS.  79 

sages;  albumin  may  persist  in  the  urine  for  weeks  or  even 
months,  and  the  heart's  action  may  be  feeble  and  irregular. 

In  many  other  cases,  including  some  very  severe  ones,  the 
restoration  of  the  patient  to  complete  health  and  strength  is 
surprisingly  rapid,  all  traces  of  the  illness  being  often  oblit- 
erated in  the  course  of  a  few  weeks. 

The  symptoms  attending  convalescence,  whether  it  be  rapid 
or  slow,  and  whether  it  follow  a  mild  or  a  grave  form  of  the 
disease,  are  often  complicated  by  the  occurrence  of  paralysis. 

Malignant  Diphtheria. 

The  term  malignant  is  by  some  applied  indiscriminately 
to  all  the  graver  forms  of  diphtheria  in  which  there  are  marked 
evidences  of  constitutional  poisoning,  but  may  more  conven- 
iently be  reserved  to  designate  in  diphtheria,  as  in  scarlatina, 
that  class  of  cases  which  are  characterized  by  exceptional 
earliness  and  intensity  in  the  systemic  poisoning  and  by  such 
rapidity  in  the  course  of  the  disease  that  the  distinctive  features 
of  its  several  stages  are  confused  together  and  unrecogniz- 
able. For  this  reason  they  often  seem  mysterious  and  inex- 
plicable by  the  laws  which  apply  to  the  ordinary  forms  of  the 
malady. 

There  are  two  kinds  of  malignant  diphtheria,  the  violent 
and  the  insidious.  The  former  differs  from  a  form  of  severe 
diphtheria  which  has  already  been  described,  only  as  the  tor- 
nado differs  from  the  ordinary  storm.  A  brief  period  of  rigors, 
vomiting  or  convulsions  is  accompanied  or  succeeded  by  a 
rapid  development  of  intense  and  extensive  inflammation  in 
the  throat  and  the  nasal  passages,  extreme  adenitis  and  a  high 
fever,  the  temperature  reaching  105°,  106°  or  107°  F.,  and  the 
pulse  being  so  rapid  that  it  can  hardly  be  counted.  Deep,  thick, 
gray,  false  membrane-  soon  overspreads  the  whole  pharyn- 
geal region,  the  vault  of  the  palate  and  sometimes  the  dorsum 
of  the  tongue,  and  obstructs  the  nasal  passages.  There  is  dis- 
charge from  the  nostrils  and  marked  factor.     Sometimes  gan- 


80  DIPHTHERIA;    ITS    NATURE    AND    TREATMENT. 

grenous  complications  occurs.  In  other  cases  the  diphtheritic 
membrane  in  the  throat  is  not  so  extensive,  hut  there  is  a 
general  purplish  redness  with  cedematous  swelling'  which  re- 
sembles phlegmonous  erysipelas. 

There  is  almost  from  the  first  an  expression  of  dullness 
and  apathy,  which  in  some  cases  soon  deepens  into  delirium 
or  coma.  In  some  cases  the  fever  continues  high  until  the 
fatal  termination,  which  may  take  place  on  the  third  or  fourth 
day.  In  other  cases  it  partially  subsides,  and  the  adynamic 
symptoms  of  septic  poisoning  and  hsemic  disorganization  al- 
ready described  predominate.  Haemorrhages  occur  from  the 
nasal  or  other  mucous  surfaces,  and  petechia?  appear  on  the 
skin.  Symptoms  of  grave  renal  or  cerebral  implication  ap- 
pear.    Death  takes  place  on  the  third  to  the  seventh  day. 

The  insidious  form  of  malignant  diphtheria  begins  with 
only  a  moderate  degree  of  febrile  disturbance,  and  the  mem- 
branous affection  in  the  throat  is  of  limited  extent.  There  is 
nasal  diphtheria,  but  this  may  be  limited  to  the  post-nasal 
region,  where  it  may  be  undetected.  Marked  pallor,  depres- 
sion and  somnolence  almost  from  the  first  indicate  an  over- 
whelming constitutional  poisoning,  from  the  effects  of  which 
and  with  the  symptoms  already  described,  the  patient  rapidly 
sinks,  and  dies  from  the  third  to  the  seventh  day  of  the  disease. 

Malignant  diphtheria  is,  happily,  in  proportion  to  the  whole 
number  of  cases  of  the  disease,  only  exceptional.  It  occurs 
with  especial  frequency  in  some  epidemics,  and  in  the  earlier 
rather  than  the  later  part  of  their  course.  Yet  sporadic 
cases  are  now  and  then  malignant.  There  seems  to  be  in 
some  individuals  and  in  some  families  a  predisposition  to 
grave  forms  of  diphtheria,  as  is  also  the  case  in  regard  to 
scarlatina.  From  the  circumstances  under  which  such  forms 
of  the  disease  occur,  and  from  facts  which  are  elsewhere 
stated,  it  is  probable  that  they  are  the  result  of  two  factors — 
first,  a  contagium  of  especial  virulence,  and,  second,  the  early 
penetration  into  the  body  of  septic  organisms. 


SYMPTOMS.  81 

Previously  impaired  vitality  or  blood  contamination  from 
insanitary  conditions  may  not  infrequently  enter  into  the  ex- 
planation of  the  more  "  insidious  "  cases. 

Gangrene. 

Though  the  belief  of  the  older  writers  that  diphtheria  is  a 
gangrenous  affection  has  been  found  to  be  erroneous,  the  two 
morbid  conditions  being  distinct,  yet  gangrene  does  occur  in  a 
small  proportion  of  cases  in  connection  with,  and  as  a  result 
of,  diphtheria. 

Gangrene  occurs  in  those  forms  of  diphtheria  in  which  the 
inflammation  is  intense  and  the  infiltration  is  deep.  A  greater 
or  less  portion  of  tissue  dies  and  sloughs  away.  Yet  it  does  not 
occur  in  all  such  cases,  nor,  as  a  rule,  in  the  worst  ones.  In 
many  fatal  cases  in  which  these  conditions  are  most  marked 
there  is  no  gangrene,  and,  per  contra,  some  cases  recover  in 
which  there  has  been  considerable  destruction  of  tissue  by  gan- 
grene, the  diphtheritic  affection  not  having  been  especially,  for- 
midable. It  is  also  to  be  noted  that  gangrene  in  diphtheria  does 
not  depend  on  the  amount  of  the  constitutional  poisoning,  for  in 
many  of  the  most  malignant  toxic  cases  gangrene  is  absent, 
and  I  have  seen  it  in  several  cases  in  which  blood-poisoning 
was  not  especially  pronounced. 

Gangrene  may  accompany  diphtheria  in  almost  any  situa- 
tion, but  does  so  most  frequently  on  the  soft  palate.  The 
entire  uvula  or  one  of  the  palatal  arches  sometimes  sloughs 
away  and  occasionally  the  soft  palate  is  perforated.  Gan- 
grene does  occur  on  the  tonsils,  though  rarely.  It  should  by 
no  means  be  associated  with  the"  gaping  cavities  sometimes 
seen  in  them  after  the  pseudo-diphtheria  which  accompanies 
follicular  tonsillitis,  in  which  there  is  usually  no  actual  loss  of 
tissue.  I  have  seen  gangrene  in  diphtheritic  patches  on  the 
inside  of  the  cheeks.  It  sometimes  occurs  on  the  lip  and 
in  cutaneous  and  vulvar  diphtheria,  etc. 

Destructive  as  the  gangrenous  process  in  diphtheria  some- 
6 


82  ■    diphtheria;  its  nature  and  treatment. 

times  appears,  yet  as  a  rule  the  actual  amount  of  deformity 
which  remains  after  cicatrization  is  comparatively  slight. 

Laryngeal  Diphtheria. 

Laryngeal  diphtheria,  or  diphtheritic  croup,  is  in  the  ma- 
jority of  cases  the  result  of  the  extension  of  the  disease  down- 
ward from  the  pharynx;  hut  in  not  a  few  cases  it  occurs  first 
in  the  larynx  and  later  makes  its  appearance  in  the  pharynx, 
while  in  some  instances  it  never  extends  ahove  the  larynx. 
Extension  from  the  pharynx  most  frequently  occurs  within  the 
first  four  or  five  days  of  the  disease,  being  comparatively  rare 
at  a  later  stage.  Its  presence  is  then  made  known  "by  the 
gradual  addition  of  the  symptoms  of  croup  to  those  of  the 
faucial  affection. 

The  amount  of  febrile  and  nervous  disturbance  that  attends 
the  onset  of  primary  laryngeal  diphtheria  is  very  various,  he- 
ing sometimes  considerable  and  in  other  cases  remarkably 
slight.  The  first  distinctive  symptoms  of  its  occurrence  are 
those  of  laryngeal  inflammation  and  irritation.  There  is 
usually  a  characteristic  cough,  which  may  he  harsh,  dry  and 
somewhat  shrill  or  hoarse  and  muffled.  It  is '  usually,  though 
not  always,  attended  with  pain.  The  voice  is  altered,  heing 
roughened  and  husky  or  weakened  and  indistinct,  and  speak- 
ing and  crying  are  often  painful.  The  respiration  is  not  usu- 
ally at  first  affected.  As  the  disease  progresses  the  symptoms 
of  laryngeal  stenosis  become  more  marked.  The  cough  is 
hoarse  and  metallic,  the  voice  raucous  or  whispering,  and  the 
respiration  is  more  and  more  obstructed  in  both  acts,  inspira- 
tion especially  being  labored,  prolonged  and  stridulous,  and 
accompanied  with  depression  above  the  sternum  and  clavicles, 
in  the  intercostal  spaces  and  over  the  diaphragm. 

In  the  earlier  stage  of  the  affection  these  symptoms  are 
usually  intermittent  or  variable,  being  increased  by  the  pres- 
ence of  mucus  in  the  larjmx,  or  excited  by  crying  and  strug- 
gling, there  being  a  tendency  in  this,  as  in  other  forms  of 


SYMPTOMS.  83 

laryngitis,  to  more  or  less  spasmodic  tightening-  from  time  to 
time.  As  the  disease  progresses  and  stenosis  increases  they 
become  more  constant. 

The  subsequent  course  of  the  malady  varies  greatly  in 
different  cases.  In  some,  which  are  unfortunately  hut  a  small 
proportion  of  all,  the  croupous  exudation  in  the  larynx  is  only 
a  thin  pellicle,  the  accompanying  tumefaction  is  not  very  great 
and  the  spasmodic  closures  not  very  severe  or  persistent.  The 
dyspnoea  and  other  symptoms  of  the  affection  may  persist  for 
a  period  varying  from  four  or  five  to  eight  or  ten  days,  vary- 
ing in  intensity  but  never  entirely  intermitting  on  the  one 
hand,  nor,  on  the  other,  hecoming  so  severe  as  to  entirely  pre- 
vent respiration.  At  length  the  membrane  exfoliates,  the 
inflammation  subsides,  and  the  symptoms  of  obstruction  dis- 
appear, either  quite  suddenly  or  gradually. 

In  the  large  majority  of  cases,  however,  the  affection  has  a 
malign,  and  often  a  treacherous  character,  which  fully  justifies 
the  dread  in  which  it  is  universally  held.  Not  infrequently, 
after  pursuing  for  some  days  a  mild  course  such  as  has  just 
been  described,  or  even  apparently  abating  in  severity,  from 
some  slight  exposure  to  cold,  or  often  without  any  evident 
explanation,  there  is  an  aggravation  of  all  the  symptoms  so 
rapid  that  almost  before  its  seriousness  is  realized  death  occurs 
from  asphyxia. 

In  other  cases  the  course  of  the  affection  is  from  the  first 
steadily  from  bad  to  worse.  The  rapidity  may  be  so  great 
that  fatal  laryngeal  occlusion  shall  take  place  within  twenty- 
four  hours  from  the  commencement  of  the  croupal  symptoms 
— a  possibility  most  important  to  be  realized.  It  occurs  still 
more  frequently  on  the  second  day  and  the  succeeding  ones 
up  to  the  fifth,  and  then  with  diminishing  frequency  up  to  the 
tenth  or  twelfth,  or  in  rare  cases  even  a  later  one. 

As  this  event  approaches  the  gravity  of  the  symptoms  be- 
comes painfully  apparent  to  the  most  inexperienced  beholder. 
The  cough  is  muffled  and  abortive.     The  voice  is  suppressed 


84  diphtheria;  its  nature  axd  treatment. 

to  a  hoarse  whisper.  The  breathing-  is  striclulous  and  labored 
in  both  acts,  inspiration  being  especially  prolonged,  and  the 
accompanying  depressions  in  the  supra-clavicular  and  other 
spaces  being  very  marked.  The  patient,  if  a  child,  either  sits 
up  constantly  or  starts  up  frequent  ry,  turning  appealingly  to 
his  parents  or  nurse  for  relief,  or  throws  himself  violently  about 
in  his  frantic  efforts  to  get  breath,  his  countenance  expressing 
alarm  and  distress,  the  hue  cyanotic. 

These  symptoms  are  often  accompanied  with  the  evidences 
of  blood-poisoning  which  have  previously  been  described.  This 
is  likely  to  be  the  case  in  proportion  to  the  time  the  disease 
has  continued,  and  to  the  amount  of  the  accompanying  pha- 
ryngeal and  nasal  affection. 

Death  in  laryngeal  diphtheria  results  from  asphyxia  caused 
by  the  occlusion  of  the  laryngeal  aperture  by  pseudo-membrane, 
by  tumefaction  of  the  mucous  membrane,  by  spasm,  by  oedema 
of  the  glottis,  or  by  a  flap  of  partially  detached  false  mem- 
brane acting  as  a  valve,  or  from  the  effects  of  the  extension  of 
the  membranous  affection  downward  through  the  bronchial 
tubes. 

The  character  and  course  of  the  symptoms  vary  very  much 
according  to  the  age  of  the  patient,  the  tendency  to  laryngeal 
stenosis  being  greater  the  younger  he  is,  from  the  fact  that 
the  laryngeal  aperture  is  both  absolutely  and  relatively 
smaller  in  children  than  in  adults,  and  in  young  children  than 
in  older  ones. 

Although  the  mode  of  termination  just  sketched  is  unfortu- 
nately that  of  the  great  majority  of  cases  of  laryngeal  diph- 
theria in  which  operative  measures  are  not  employed,  yet  there 
are  exceptional  recoveries  which  prove  that  no  case  is  abso- 
lutely hopeless  unless  it  is  made  so  by  complications.  Some- 
times when  death  by  asphyxia  seems  imminent  the  obstructing 
false  membrane  is  opportunely  coughed  up.  I  have  known  of 
several  striking  instances  in  which  life  has  been  thus  saved 
almost  at  the  last  moment. 


symptoms.  85 

Tracheal  and  Bronchial  Diphtheria. 

Diphtheria  of  the  trachea  and  the  bronchial  tubes  is  usually 
the  result  of  the  extension  downward  of  the  disease  from  the 
larynx,  though  in  some  cases  it  occurs  without  any  implication 
of  the  larynx  in  connection  with  pharyngeal  or  nasal  diph- 
theria. It  is  a  very  common  accompaniment  of  laryngeal 
diphtheria,  and  is  the  most  frequent  cause  of  the  failure  of 
tracheotomy  or  intubation  to  avert  a  fatal  issue.  In  some 
instances  it  extends  through  the  bronchial  tubes  to  their  ulti- 
mate ramifications  and  into  the  air-cells  themselves. 

The  pse  ado -membrane  in  these  localities  is  of  the  kind  de- 
scribed as  "  croupous,"  lying  loosely  upon  the  mucous  mem- 
brane. It  is  of  various  degrees  of  thickness  and  is  usually  of 
not  very  firm  consistency. 

Among  the  most  usual  results  of  tracheo-bronchial  diph- 
theria are  broncho-pneumonia  and  pulmonary  collapse.  Its 
symptoms  are  those  of  bronchitis  with  marked  dyspnoea  and 
cyanosis,  which  are  frequently  complicated  by  those  of  the 
affections  just  mentioned.  Owing  to  the  dyspnoea  caused  by 
the  laryngeal  affection,  the  physical  signs  of  tracheal  and 
bronchial  diphtheria  are  obscure  and  indistinct.  Its  presence 
is  in  rare  cases  made  a  certainty  during  life  by  the  coughing 
up  of  membranous  casts  of  the  bronchial  tubes. 

Diphtheria  of  the  Ear. 

Diphtheria  of  the  Eustachian  tubes,  the  tympanum  and  the 
external  ear  is  usually  the  result  of  the  extension  of  the  disease 
to  those  parts  from  the  pharynx.  The  symptoms  are  those  of 
ordinary  otitis  media,  with  the  addition  of  diphtheritic  exuda- 
tion. This  lines  the  Eustachian  tubes,  follows  the  suppura- 
tive inflammation  through  the  cava  tympani,  and  after 
perforation  of  the  drum  overspreads  the  wall  of  the  meatus 
externa  and  sometimes  the  adjacent  cutaneous  surfaces.     In 


86  diphtheria;  its  nature  and  treatment. 

the  middle  ear  diphtheritic  otitis  is  usually  very  destructive, 
hearing'  being  permanently  impaired  or  destroyed. 

Diphtheritic  otitis  media  rarely,  if  ever,  occurs  in  the  course 
of  primary  diphtheria.  It  has  been  observed  in  the  diphtheria 
which  follows  small-pox  and  some  other  diseases,  hut  in  the 
great  majority  of  all  cases  is  a  complication  or  sequela  of 
scarlatina.  So  uniform,  according  to  my  experience,  is  this 
relation  of  the  two  diseases,  that  I  long  ago  learned  to  regard 
the  occurrence  of  otitis  in  connection  with  diphtheria  as  strong 
presumptive  evidence  that  the  diphtheria  was  of  scarlatinal 
origin.  In  a  number  of  such  cases  in  which  that  origin  had 
not  been  recognized,  I  have  learned,  on  carefully  tracing  back 
their  early  history,  that  there  had  been  characteristic  symp- 
toms of  scarlatina,  though  so  slight  and  so  transient  as  to 
have  been  disregarded.  Several  of  these  cases  have  been  seen 
by  me  in  consultation  with  other  physicians,  who  have  been 
convinced  of  their  scarlatinal  origin  by  a  careful  consideration 
of  evidences  which  had  previously  escaped  their  notice  or  been 
regarded  as  inconclusive. 

Diphtheria  of  the  meatus  externa  not  resulting  from  otitis 
media  has  been  observed  in  rare  cases.  It  has  usually,  at 
least,  supervened  upon  a  catarrhal  affection  of  the  part 

Diphtheria  of  the  Eye. 

Diphtheritic  conjunctivitis  may  occur  as  a  primary  affec- 
tion or  may  supervene  upon  purulent  conjunctivitis.  It  is  also 
in  rare  cases  consecutive  to  nasal  diphtheria  by  extension 
through  the  lachrymal  duct. 

It  varies  very  much  in  intensity,  being  sometimes  a  com- 
paratively mild  and  limited  affection,  but  more  often  very 
severe  and  destructive  to  the  eye. 

It  begins  more  usually  upon  the  palpebral  conjunctiva. 
The  diphtheritic  exudation  is  sometimes  in  thin  patches  which 
cannot  easily  be  detached;  in  other  cases  it  is  thick,  gray  and 
coherent,  and  can  be  stripped  off  in  large  pieces. 


SYMPTOMS.  87 

When  the  affection  is  primary  and  severe  it  is  attended 
with  great  swelling-,  heat,  pain  and  sensitiveness  in  the  eye- 
lids. The  conjunctiva,  at  first  red  and  vascular,  is  later  dry, 
smooth  and  of  a  grayish  yellow.  This  is  the  result  of  the 
dense  infiltration  of  its  substance,  which  compresses  the  blood- 
vessels and  checks  the  circulation.  Numerous  extravasations 
of  blood  may  be  seen  upon  it.  This  dense  infiltration  in  the 
chemosed  ocular  conjunctiva  strangulates  the  blood-vess3ls 
which  supply  the  cornea  and  thus  greatly  interferes  with  its 
nutrition;  hence  the  cornea  is  very  liable  to  undergo  ulcera- 
tion, suppuration  and  perforation.  The  earlier  in  the  course 
of  the  affection  this  ulceration  occurs  the  more  extensive  and 
destructive  it  is  likely  to  be. 

After  a  few  days  the  conjunctiva  becomes  less  tense  and 
hard  and  more  moist  and  vascular,  and  there  is  a  copious  pur- 
ulent discharge.  The  membranous  exudations  become  softened 
and  loosened,  and  finally  are  detached,  but  relapses  are  very 
liable  to  occur. 

Diphtheritic  conjunctivitis  may  be  limited  to  one  eye,  but  in 
most  cases  affects  both.  Its  discharge  is  exceedingly  contagi- 
ous. It  is  not  a  very  common  affection,  but  it  sometimes 
occurs  epidemically.  It  is  much  less  common  in  this  country 
than  in  some  parts  of  Europe.  Dr.  W.  O.  Moore  informs  me 
that  in  the  records  of  the  New  York  Eye  and  Ear  Infirmary 
for  fifteen  years  but  two  cases  of  ocular  diphtheria  appear. 

Diphtheria  of  the  CEsophagus,  Stomach  and  Intestines. 

Diphtheria  of  the  CEsophagus  is  very  rare  and  is  usually 
secondary  to  other  diseases. 

The  symptoms  of  oesophageal  diphtheria  are  not  distinctive. 
They  would  of  course  be  expected  to  be  pain,  dysphagia,  chok- 
ing sensations,  vomiting,  reflex  cough,  etc.  Yet  these  symp- 
toms have  be«n  absent  in  cases  in  which  the  autopsy  revealed 
the  existence  of  the  affection,  and  have  been  present  in  many 
cases  in  which  no  such  condition  existed.     In  a  majority  of  the 


88  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

cases  in  which  it  has  occurred  its  presence  has  been  unsus- 
pected until  discovered  at  the  autopsy.  Hence  its  diagnosis  is 
in  a  large  proportion  of  cases  difficult  or  impossible.  This 
obscurity  is  characteristic  of  oesophageal  affections  in  general. 
Of  forty-four  cases  reported  by  Steffen,1  including  diphtheria, 
catarrhal  inflammation,  ulceration,  gangrene,  etc.,  as  shown 
at  the  autopsy,  the  diagnosis  had  been  made  in  only  three. 

Cicatricial  stricture  of  the  oesophagus  has  in  a  few  cases 
occurred  as  a  sequel  of  diphtheritic  ulceration. 

Diphtheria  of  the  stomach  is  also  a  rare  affection,  and  its 
symptoms  are  necessarily  obscure.  It  has  been  found  in 
some  autopsies  affecting  either  limited  portions  of  the  gastric 
mucous  membrane  or,  in  a  few  instances,  nearly  its  entire  sur- 
face. 

Diphtheritic  inflammation  of  the  mucous  membrane  of  the 
small  and  the  large  intestine  has  also  occurred.  Its  existence 
has  in  a  few  instances  been  made  known  during  life  by  the 
passing  of  membranous  casts  of  the  bowel,  but  in  most  cases 
has  only  been  revealed  at  the  autopsy. 

Diphtheria  of  the  anus  has  been  observed  in  quite  a  number 
of  instances,  sometimes  extending  upward  into  the  rectum  or 
over  the  adjoining  skin. 

Diphtheria  op  the  Genito-Urinary  Organs. 

Diphtheria  has  occurred  in  the  urinary  bladder  in  chronic 
cystitis  and  in  connection  with  stone  in  the  bladder,  and  also 
following  various  surgical  operations  on  that  organ.  It  has 
also  invaded  the  uterus  as  a  puerperal  complication  and  after 
surgical  operations.  It  sometimes  occurs  in  the  vagina  under 
the  same  circumstances. 

Diphtheria  of  the  vulva  is  a  not  infrequent  form  of  the  dis- 
ease. It  usually  occurs  daring  the  endemic  or  epidemic  prev- 
alence of  the  pharyngeal  affection,  sometimes  as  a  complica- 

1  Quoted  by  Dr.  H.  D.  Fry,  in  a  Valuable  and  exhaustive  article  on 
this  subject,  Am.  Jour.  Med.  Sc,  October,  1885. 


SYMPTOMS.  89 

tion  in  the  same  patient,  and  sometimes  in  others  who  have 
been  exposed  to  the  contagion  of  the  disease.  There  is  usually 
some  accompanying-  inguinal  adenitis,  but  this  may  be  slight 
or  absent.  The  affection  sometimes  extends  over  the  adjoin- 
ing skin,  and  in  rare  cases  involves  both  the  vulva  and  the 
anus  with  the  region  between  them. 

Diphtheria  of  the  Skin  and  op  Wounds. 

That  diphtheria  shall  affect  the  skin  it  is  necessary  that 
the  epidermis  be  first  removed  or  penetrated.  Thus  in  former 
times  it  often  invaded  blistered  surfaces,  leech-bites  and  ven- 
esection wounds.  Its  frequent  occurrence  on  the  skin  of  the 
upper  lip  from  the  excoriating  effect  of  the  acrid  discharge 
from  the  nostrils  in  nasal  diphtheria  has  been  referred  to. 
Diphtheria  having  once  gained  a  foothold  on  an  abraded  sur- 
face, spreads  over  the  contiguous  sound  skin,  making  its  way 
along  the  corion  and  displacing  the  epidermis  by  a  process  of 
destructive  inflammation.     It  usually  extends  downward. 

Diphtheria  also  invades  the  surface  of  wounds  where  no 
true  skin  remains.  This  is  especially  liable  to  occur  in  hospi- 
tals in  the  presence  of  similar  conditions  to  those  which  pro- 
duce hospital  gangrene,  with  which  it  is  often  complicated. 
Diphtheria  of  wounds  is  characterized  by  the  formation  upon 
them  of  a  whitish,  grayish  or  greenish  pellicle  of  varying 
thickness.  The  purulent  discharge  is  dried  up  and  is  replaced 
by  an  acrid,  ichorous  fluid.  The  edges  of  the  wound  are  thick- 
ened and  cedematous,  and  sometimes  surrounded  by  an  erysip- 
elatous inflammation.  The  affection  may  be  superficial  or 
deep,  with  a  tendency  to  become  phagedenic  or  gangrenous. 
Septic  absorption  is  liable  to  occur  in  this  as  in  other  forms  of 
the  disease. 

Albuminuria  and  Nephritis. 
If  the  urine  of  patients  suffering  with  diphtheria  be  ex- 
amined dairy  it  will,  in  about  half  of  all  cases,  be  found  at  some 
time  in  the  course  of  the  affection  to  contain  albumin. 


90  diphtheria;  its  nature  and  treatment. 

According-  to  M.  Sanne,1  out  of  410  cases  in  which  albumin 
was  sought  it  was  found  in  224.  According  to  Dr.  J.  Lewis 
Smith,2  of  sixty -two  cases  examined  twenty -four  were  attended 
with  albuminuria,  and  thirty-eight  were  exempt. 

Albuminuria  makes  its  first  appearance  in  rare  cases  of 
diphtheria  as  early  as  the  first  or  second  day,  then  with  in- 
creasing frequency  until  the  eighth  or  ninth,  then  with  dimin- 
ishing frequency  until  the  eleventh  or  twelfth,  and  in  rare 
cases  subsequently  to  that  period.  It  begins,  therefore,  in 
the  great  majority  of  cases  during  the  period  at  which  there 
is  the  greatest  intensity  of  the  constitutional  disease.  In  view 
of  this  circumstance  it  cannot  be  doubted  that  toxaemia  is  its 
principal  cause  in  most  serious  cases.  This  conclusion  is  con- 
firmed by  the  fact,  established  by  many  careful  observers,  that 
it  is  usually  in  those  cases  of  diphtheria  in  which  other  evi- 
dences of  constitutional  poisoning  are  most  marked  that 
albuminuria  in  its  more  serious  forms  is  seen. 

It  is,  however,  important  to  remember  that  there  are  also 
various  other  known  and  unknown  causes  of  albuminuria  which 
may  be  present  in  diphtheria,  and  which  may  be  wholly  or 
partially  responsible  for  its  occurrence,  especially  in  its  slighter 
manifestations.  Albuminuria  occurs  not  only  in  the  course 
of  infectious  diseases  but  also  in  connection  with  various  other 
febrile  and  catarrhal  affections,  including  non-diphtheritic  an- 
ginas. It  occurs  not  infrequently  in  persons  apparently  in 
perfect  health.3  Among  its  leading  causes  is  exposure  to  cold, 
a  circumstance  which  often  precedes  an  attack  of  diphtheria. 

It  is  evident,  therefore,  that  the  idea,  advanced  by  some 
authors,  that  the  presence  or  absence  of  albuminuria  may  be 
a  diagnostic  criterion  between  diphtheritic  and  pseudo-diph- 
theritic affections  is  erroneous.  It  is  equally  evident  that 
the  argument  which  has  often  been  urged,  that  because  albu- 
minuria sometimes  appears  at  an  early  stage  of  diphtheria, 

1  Op.  cit.  p.  129.  2 "  Diseases  of  Children,"  1886,  p.  312. 

3 Flint,  "Practice  of  Medicine,"  1881,  p.  809. 


SYMPTOMS.  91 

therefore  the  disease  is  a  primarily  constitutional  one,  is  based 
on  a  misconception  of  the  facts. 

In  a  considerable  proportion  of  cases  in  which  albuminuria 
is  due  to  extrinsic  causes,  or  even  to  a  slight  degree  of  diph- 
theritic poisoning,  it  is  small  in  amount,  transient,  accom- 
panied with  few  or  no  renal  casts  and  with  no  symptoms 
of  uraemic  poisoning,  and  is  of  no  serious  prognostic  sig- 
nificance. 

But  many  cases  remain  which  result  from  the  constitu- 
tional infection,  are  in  direct  proportion  to  the  degree  of  that 
infection,  are  accompanied  with  more  or  less  profound  uraemia, 
and  both  from  the  mischief  they  indicate  and  the  additional 
mischief  thej^  cause  are  of  grave  significance. 

The  urine  presents  various  appearances;  it  is  usually  nearly 
normal  in  color  and  transparency,  but  frequently  becomes 
cloudy  on  cooling  from  the  precipitation  of  urates.  It  is  often 
rather  scanty  and  of  increased  specific  gravity,  especially  in 
the  earlier  stage.  In  rare  cases  it  is  dark-colored  or  smoky 
from  the  presence  of  blood.  The  amount  of  albumin  varies, 
but  in  severe  cases  it  is  usually  in  considerable  quantity.  In 
such  cases  there  are  also  present  granular,  epithelial  and 
hyaline  casts. 

Of  233  cases  of  diphtheria  with  albuminuria,  according  to 
M.  Sanne,  142  died,  and  91  recovered;  but  of  160  cases  without 
albuminuria,  97  recovered  and  63  died.  Of  22  cases  without 
albuminuria,  according  to  Cadet  de  Gassicourt,1  12  recovered 
and  10  died.  In  29  cases  in  which  there  was  only  a  trace  of 
albumin,  12  recovered  and  IT  died.  In  19  cases  in  which  the 
amount  of  albumin  was  considerable,  8  recovered  and  11  died. 
In  16  cases  in  which  the  amount  of  albumin  was  very  large,  3 
recovered  and  13  died. 

While  these  figures  roughly  confirm  the  views  expressed 
above  as  to  the  unfavorable  significance  of  albuminuria,  yet 
they  give  no  precise  information  on  that  point,  since  they  make 
1Rev.  Mens,  des  Mai.  de  FEnf.,  November,  1884. 


92  diphtheria;  its  nature  and  treatment. 

no  distinction  between  deaths  from  laryngeal  asphyxia  and 
from  the  effects  of  constitutional  poisoning*.  Much  more  in- 
structive are  the  following-  figures,  given  by  Dr.  J.  Lewis 
Smith : x  Of  18  cases  of  diphtheria  without  membranous  lar- 
yngitis and  with  albuminuria,  13  died  and  5  recovered;  while  of 
31  such  cases  without  albuminuria,  4  died  and  27  recovered. 
"In  nearly  all  the  specimens  which  contained  albumin — all 
but  three  or  four — casts,  usually  granular,  but  now  and  then 
hyaline,  and  sometimes  both  kinds  in  the  same  specimens, 
were  observed.  In  those  cases  of  albuminuria  which  recov- 
ered, there  were  comparatively  few  casts  or  none." 

The  assertion  of  Trousseau  that  albuminuria  in  diphtheria 
"  has  only  a  limited  significance  in  relation  to  prognosis  and 
treatment,"  can  therefore  be  accepted  only  with  important 
qualifications. 

The  duration  of  albuminuria  in  diphtheria  varies  from  one 
or  two  days  to  one  or  two  weeks,  or  in  rare  cases  a  longer 
period.  It  very  rarely  becomes  chronic.  It  is  sometimes  re- 
markably variable  or  intermittent.  I  have  in  some  instances 
seen  its  variations  closely  correspond  to  those  of  the  local  dis- 
ease, the  albumin  repeatedly  diminishing  or  disappearing  with 
the  cessation  of  nasal  discharges  or  the  exfoliation  of  mem- 
branes, and  again  becoming  abundant  on  the  occurrence  of  re- 
lapses. 

Albuminuria  in  diphtheria  is  in  only  a  very  small  propor- 
tion of  cases  attended  with  any  marked  degree  of  oedema. 
Trousseau  estimates  this  proportion  in  his  own  experience  at 
one  case  in  twenty.  It  is  especially  liable  to  occur  in  those 
cases  in  which  blood  corpuscles  are  present  in  the  urine. 

Certain  differences  between  the  albuminuria  of  diphtheria 
and  that  of  scarlatina  are  noteworthy.  The  former  usually 
begins  during  the  active  continuance  of  the  disease  and  before 
its  tenth  day,  the  latter  at  a  later  period  and  as  a  sequela. 
The  former  is  rarely  accompanied  with  oedema;   it  is  a  fre- 

1  Loc.  cit. 


SYMPTOMS.  93 

quent  attendant  of  the  latter.  The  former  in  a  smaller  pro- 
portion of  cases  denotes  important  disease  of  the  kidneys,  but 
when  this  occurs  it  is  of  more  serious  prognostic  import. 
The  former  very  rarely  becomes  chronic;  the  latter  not  very 
infrequently  does  so. 

The  Lungs. 

The  pulmonary  conditions  which  are  liable  to  occur  in  con- 
nection with  laryngeal,  tracheal  and  bronchial  diphtheria  have 
already  been  referred  to.  Their  symptoms  are  the  same  as 
when  they  result  from  other  causes,  but  their  physical  signs 
are  often  so  obscured  by  the  dyspnoea  caused  by  the  laryn- 
geal stenosis  that  their  diagnosis  is  difficult  or  impos- 
sible. The  occurrence  of  an  increase  of  febrile  symptoms, 
with  excessive  rapidity  of  respiration  and  with  or  without 
cough  in  the  course  of  diphtheritic  croup,  either  before  or  after 
tracheotomy  or  intubation,  should  suggest  the  probability  of 
an  inflammatory  pulmonary  complication  having  occurred 
and  lead  to  a  careful  examination  of  the  chest.  Broncho- 
pneumonia usually  results  from  the  impeded  respiration  caused 
by  laryngeal  stenosis  or  from  the  extension  downward  of  fibri- 
nous or  catarrhal  bronchitis.  It  is  maintained  by  some  and 
denied  by  others  that  pneumonia  may  be  caused  by  the  draw- 
ing of  blood  into  the  lungs  during  tracheotomy. 

Bronchitis,  broncho-pneumonia,  lobar  pneumonia,  pulmo- 
nary congestion,  pulmonary  oedema  and  pleurisy  may  occur  in 
non-laryngeal  diphtheria  attended  with  septic  poisoning,  as -in 
other  adynamic  toxsemic  diseases. 

The  Heart. 

The  symptoms  resulting  from  the  functional  disturbances 
or  organic  lesions  of  the  heart  in  diphtheria,  have  been  referred 
to  in  describing  the  various  stages  and  forms  of  the  disease. 
These  symptoms  may  be  due  (1)  to  cardiac  paralysis;  (2)  my- 
ocardial degeneration  and  consequent  weakening  and  dilata- 


94  DIPHTHERIA-    ITS   NATURE    AND    TREATMENT. 

tion  of  the  heart-walls;  (3)  endocarditis  with  fibrinous  deposits 
upon  the  valves  of  the  heart;  (4)  gradual  exhaustion  of  the 
vital  forces;  (5)  the  formation  of  thrombi  in  the  cavities  of 
the  heart  (ante-mortem  heart-clot).  Frequently  several  of 
these  causes  act  simultaneously,  especially  in  the  later  stage 
of  fatal  cases. 

The  occurrence  of  organic  lesions  may  be  recognized  by 
the  usual  physical  signs  of  these  conditions.  The  symptoms 
of  heart-failure  may  be  gradual  and  jxrogressive  or  sudden 
and  unexpected,  and  may  appear  early  in  the  disease  or  at 
a  late  period  and  after  apparent  convalescence. 

Eruptions. 

Eruptions  have  been  described  by  various  observers  of 
diphtheria  as  having  occurred  in  a  portion  of  the  cases  of  the 
disease  in  some  epidemics.  The  predominant  form  has  resem- 
bled the  exanthem  of  scarlatina,  but  other  forms  have  been 
similar  to  that  of  measles  or  that  of  roseola  or  to  urticaria, 
and  still  another  has  been  vesicular.  These  eruptions  are 
attended  with  no  special  symptoms  and  are  not  followed  by 
desquamation.  They  have  not  usually  been  observed  to 
have  any  definite  significance  as  to  the  gravity  of  the  disease 
or  its  prognosis.  In  the  observation  of  many  hundreds  of 
cases  of  diphtheria  I  have  never  seen  an  accompanying  erup- 
tion that  was  not  evidently  a  purely  accidental  complication. 
In  the  observations  of  M.  Sanne *  one  case  in  fifty  was  attended 
with  an  eruption.  The  supposition  of  some  writers,  that  these 
eruptions  hold  the  same  relation  to  diphtheria  that  those  oc- 
curring in  typhus  or  typhoid  fever  hold  to  those  diseases, 
seems  to  be  negatived  by  the  extreme  rarity  of  their  occur- 
rence and  by  their  lack  of  uniformity  in  type.  It  is  reasonable 
to  suppose  that  some  of  the  recorded  cases  may  have  been  in 
reality  cases  of  scarlatina,  in  which  the  eruption  was  so  slight 
and  so  transient  and  the  accompanying  symptoms  so  incom- 

1  Op.  cit.  p.  138. 


SYMPTOMS.  95 

plete  that  the  real  nature  of  the  affection  was  not  recognized. 
The  majority  are  doubtless  merely  cases  of  erythema  "  sim- 
plex "  or  "  fugax,"  occasioned  by  the  fever  under  certain  indi- 
vidual or  local  or  epidemic  conditions. 

Purpura  haemorrhagica  has  been  already  referred  to  as  not 
infrequently  occurring  in  the  course  of  malignant  and  grave 
forms  of  septic  diphtheria. 


CHAPTER  V. 

THE  PRIMARY  NATURE  OP  DIPHTHERIA. 

Is  diphtheria  primarily  a  local  or  a  constitutional  disease  ? 

The  importance  of  this  question  arises  from  the  fact  that 
its  answer  must  be  fundamental  to  any  rational  theory  of 
treatment. 

In  1876, 1  stated *  that  the  result  of  my  clinical  observa- 
tions, which  had  included  the  early  stages  of  many  cases, 
had  been  to  make  me  a  convert  to  the  minority,  who  believe 
that  the  source  of  the  constitutional  disease  is,  in  the  great 
majority  of  cases  at  least,  to  be  found  in  the  local  affection. 

I  have  since  been  confirmed  in  that  view  by  many  subse- 
quent clinical  observations,  and  also  by  important  corrobora- 
tive facts  which  have  been  elicited  in  pathological  and  bac- 
teriological research  by  investigators  in  this  and  in  other 
countries,  and  which  have  been  stated  in  the  chapter  on 
etiology. 

I  shall  now  present  some  of  the  clinical  facts  upon  which 
this  belief  is  based,  and  shall  consider  some  of  the  statements 
and  arguments  which  have  been  advanced  in  opposition  to  it. 

First. — Diphtheria  occurs  in  the  great  majority  of  cases 
upon  the  mucous  membrane  of  the  fauces,  the  larynx,  the 
nasal  passages  and  the  mouth,  or,  in  other  words,  the  outer 
avenues  of  entrance  of  inspired  air  and  of  food  and  drink,  and 
with  the  greatest  relative  frequency  in  exactly  those  positions 
where  particles  of  matter  introduced  by  them  would  'most 

1 "  Diphtheria  and  its  Treatment,  with  Statistics  of  one  hundred  and 
seventy-nine  Cases."  Transactions  of  the  New  York  Academy  of  Medi- 
cine, 1876,  p.  286. 


THE  PRIMARY  NATURE  OF  DIPHTHERIA.  97 

naturally  be  deposited,  which  fact  suggests  a  probability 
tbat  the  disease  is  directly  and  locally  caused  by  such  contact 
or  implantation.  This  probability  is  greatly  strengthened  by 
the  fact  that  it  occurs  in  sharply  limited,  irregular  and  non- 
symmetrical areas,  which  is  not  the  case  with  the  throat- 
inflammations  resulting  from  blood-diseases,  such  as  scarla- 
tina and  small -pox.  This  probability  is  still  further  strength- 
ened by  the  fact  that  when  it  attacks  the  skin,  which  has  a 
more  efficient  protection  in  its  epidermis,  it  affects  only  such 
portions  of  it  as  have  been  deprived  by  wounds  and  abrasions 
of  that  protection.  These  circumstances  taken  together  con- 
stitute a  very  strong  a  priori  argument.  Althoug'h  they 
have  not  escaped  previous  notice  I  have  never  seen  a  satisfac- 
tory explanation  of  them  in  accordance  with  the  opposite 
theory  of  the  disease. 

It  is  argued,1  per  contra,  "  If  diphtheria  were  a  local  dis- 
ease at  first,  commencing  in  the  throat  and  then  becoming 
constitutional  by  absorption,  what  organs  would  be  more  ex- 
posed to  the  reception  of  its  poison  than  the  digestive  pas- 
sages, which  are  in  habitual  contact  with  the  debris  of  the 
false  membranes  swallowed  with  the  saliva  and  with  food, 
when  they  are- not  constantly  bathed  in  an  ichorous  fetid 
liquid  which  proceeds  from  the  fauces  ?  In  spite  of  these  con- 
ditions, so  favorable  to  the  development  of  false  membranes, 
their  presence  in  the  oesophagus,  the  stomach  and  the  intes- 
tine is  exceptional."  This  argument  has  apparently  great 
force,  for  while  it  may  readily  be  answered,  in  so  far  as  the 
stomach  and  intestines  are  concerned,  that  the  gastric  juice 
has  probably  the  property  of  destroying  the  infectiousness  of 
the  materials  referred  to,  some  other  explanation  is  required 
for  the  exemption  of  the  oesophagus,  which  is  most  directly 
exposed  to  them  and  is  not  thus  defended.  That  explanation 
may  be  found  in  the  protection  which  it  receives  from  the  es- 
pecially dense  epithelium  which  covers  its  mucous  membrane. 
^ann^,  Op.  cit.,  p.  362. 


98  diphtheria;  its  nature  and  treatment. 

Zenker  and  von  Ziemssen1  remark:  "The  sharply  defined 
anatomical  and  histological  differences  between  the  mucous 
membrane  of  this  organ  and  the  parts  with  which  it  connects 
at  either  end  are  usually  accompanied  with  an  equally  well- 
defined  limitation  of  pathological  processes,  particularly  the 
inflammatory."  Another  and  more  comprehensive  explana- 
tion of  the  exemption  of  the  regions  referred  to  from  diphthe- 
ritic inflammation  has  been  referred  to  in  the  chapter  on 
etiology,  in  the  fact  that  free  oxygen  is  under  ordinary  con- 
ditions absent  in  them,  and  that  the  bacterium  of  diphtheria 
is  probably  aerobious — either  explanation  being  in  accordance 
with  the  theory  of  the  local  character  of  the  disease. 

Second. — The  constitutional  disease,  as  I  have  more  fully 
stated  in  the  chapter  on  symptoms,  is,  in  the  order  of  time, 
not  antecedent  to  but  consequent  upon  the  local  affection. 
Fever,  rigors,  or  even  convulsions  may  indeed  be  the  first 
symptom  to  attract  attention  and  do  precede  the  formation 
of  membrane,  but  in  all  cases,  if  the  throat  be  examined  at 
that  stage  of  the  disease,  inflammation  will  be  found  to  be 
present. 

A  common  source  of  error  on  this  point  is  that  the  "  symp- 
tomatic "  fever  and  nervous  disturbances  which  are  common 
to  the  onset  of  many  inflammatory  affections,  including  sim- 
ple catarrhal  anginas,  are  strangely  confounded  with  the  evi- 
dences of  constitutional  infection  or  blood-poisoning,  which  in 
diphtheria,  as  is  universally  agreed,  consist  of  pallor,  somno- 
lence, weakness,  etc.  In  most  clinical  descriptions  of  diphthe- 
ria, the  last-mentioned  symptoms  are  said  to  usually  occur 
at  various  periods  of  the  disease  subsequent  to  the  local  in- 
flammation and  the  formation  of  membrane. 

Another  cause  of  much  error  on  this  point  is  the  fact  that 
in  some  cases  in  which  pseudo-membranous  exudation  already 
exists  there  has  been  no  complaint  of  pain  or  soreness  of  the 
throat.     The  more  strictly  the  physician  observes  the  rule  to 

1 "  Diseases  of  the  Oesophagus,"  Ziemssen's  Cyclopaedia,  vol.  viii. 


THE    PRIMARY    NATURE    OF    DIPHTHERIA.  99 

examine  the  throat  of  every  sick  child,  the  fewer  will  be  the 
cases  in  which  he  will  suppose  the  constitutional  symptoms  to 
have  preceded  the  local  ones. 

Another  source  of  error  is  the  fact  that  diphtheria  often 
supervenes  upon  some  other  disease.  A  child,  for  instance? 
has  taken  cold,  from  the  effects  of  which  he  is  drooping-  and 
feverish  for  several  days.  Upon  the  catarrhal  sore-throat 
thus  produced  diphtheria  sets  in.  The  previous  symptoms 
are  naturally  supposed  to  have  been  those  of  the  invasion  of 
the  latter  disease,  when  in  fact  they  were  nothing-  of  the  kind. 

Still  another  source  of  error,  and  a  very  important  one,  is 
the  fact  that  false  membrane  often  occurs  in  some  concealed 
situation.  That  situation  is  most  usually  the  posterior  nares. 
I  have  in  a  number  of  instances  found  an  explanation  of  con- 
stitutional symptoms  of  diphtheria  which  were  otherwise  un- 
accountable, by  washing  portions  of  false  membrane  from 
that  locality  by  nasal  syringing.  Dr.  D.  Bryson  Delavan  has 
informed  me  that  he  has  seen  quite  a  number  of  instances  of 
physicians  or  nurses  who,  after  attendance  upon  cases  of 
diphtheria,  have  suffered  from  the  constitutional  symptoms  of 
the  disease,  although  no  membrane  has  been  visible  in  the 
throat  or  elsewhere  by  ordinary  modes  of  inspection;  but  on 
examining  the  posterior  nares  with  the  rhinoscopic  mirror, 
patches  of  unmistakable  diphtheritic  membrane  have  been 
seen  in  that  situation.  In  one  fatal  case  with  symptoms  of 
diphtheritic  poisoning  which  was  reported  by  me,1  the  only 
false  membrane  was  found  post-mortem  in  the  bronchial  tubes. 
Such  facts  furnish  an  obvious  explanation  of  cases  which  have 
been  adduced  in  support  of  the  assertion  that  diphtheria  may 
occur  without  a  diphthera. 

To  the  statements  which  have  just  been  made  are  opposed 
contradictory  ones  by  writers  of  great  excellence  and  author- 
ity. M.  Sanne,  who  argues  with  earnestness  and  force  in  favor 
of  the  primarily  constitutional  nature  of  diphtheria,2  says,  "  It 

1  New  York  Medical  Record,  April  16,1887.  2  Op.  eit.,  p.  363. 


100  DIPHTHERIA;     ITS    NATURE    AND    TREATMENT. 

is  quite  as  common,  if  not  more  so,  to  find  the  diphtheritic 
poisoning  evident  from  the  outset,  and  it  is  those  cases  in 
which  it  is  most  intense  which  begin  thus ;  the  false  membrane 
is  then  but  an  unimportant  element."  But  when  we  turn 
from  that  statement,  made  in  the  stress  of  argument,  to  the 
chapters  in  which  he  describes  the  symptoms  of  the  disease, 
we  find  the  onset  of  the  different  forms  thus  delineated: 
"Benign  form. — This  commences  by  a  debut  like  one  of  the 
non-diphtheritic  inflammatory  anginas,  provided  they  acquire 
a  certain  violence."  The  usual  symptoms  of  the  onset  of  this 
class  of  affections — fever,  rigors,  anorexia,  lassitude,  headache 
— are  mentioned  (page  118).  ''The  same  day  or  the  next  one 
the  patient,  if  he  is  old  enough,  complains  of  a  sore  throat," 
etc.  "Examination  of  the  throat  shows  from  the  outset 
(d'abord)  a  more  or  less  vivid  redness  of  the  pharynx."  (page' 
182).  No  symptom  distinctive  of  diphtheritic  poisoning  is 
mentioned  in  connection  with  the  onset  of  this  form. — " Infec- 
tious form. — The  commencement  is  the  same"  (as  in  the  pre- 
vious form),  "but  at  the  end  of  a  feiv  days  characteristic 
symptoms  appear"  (page  119).  One  of  these  is  (page  120) 
that  "the  complexion,  at  first  bright,  becomes  pale,  livid, 
leaden."  (The  italics  are  mine.)  The  malignant  form  pre- 
sents two  varieties.  "  In  the  first "  (page  122),  "  which  may  be 
called  forme  foudroyante,  the  symptomatic  complex  is  the 
same  as  in  the  preceding  form,  and  is  distinguished  from  it 
only  by  the  rapidity  ivith  which  the  symptoms  succeed."  In 
this  form  the  false  membranes  may  be  very  extensive  or  very 
slight,  but  "  however  limited  they  may  be  the  neck  presents 
an  enormous  tumefaction"  from  glandular  swelling.  What 
description  could  be  more  suggestive  of  toxic  absorption  from 
a  local  source  ?  The  second  variety,  the  "  insidious  form, 
leads  in  the  beginning  to  an  expectation  of  benignity  which 
proves  cruelty  deceptive.  The  lesions  are  unimportant,  but 
they  extend  from  the  throat  into  the  nose  " — a  situation  which 
M.  !Sanne  elsewhere  recognizes  as  especially  favorable  to  toxic 


THE    PRIMARY   NATURE    OF    DIPHTHERIA.  101 

absorption.  In  short,  while  we  find  in  the  admirable  general 
descriptions  of  diphtheria  by  this  author,  which  may  fairly  be 
presumed  to  include  its  more  usual  manifestations  much  which 
is  illustrative  of  constitutional  poisoning"  from  a  local  source, 
we  search  in  vain  for  distinctive  evidences  of  diphtheritic  poi- 
soning- at  the  initial  stage  of  the  disease,  unless,  indeed,  the 
fever  and  the  concomitant  nervous  disturbances  which  attend 
the  primary  inflammation  are  to  be  so  regarded. 

This  view  is  not  without  advocates.  Since  the  fever,  how- 
ever, behaves  in  diphtheria  precisely  as  it  does  in  various 
simple  catarrhal  anginas — that  is  to  say,  as  a  general  rule 
begins  and  ends  with  the  inflammation,  and  is  in  direct  propor- 
tion to  it — it  is  most  natural  to  suppose  that  it  is,  as  in  them, 
simply  the  attendant  and  the  result  of  the  inflammation.  Ex- 
ceptionally, it  is  true,  it  apparently  precedes  the  latter  by  a 
little,  or  is  disproportionately  high,  but  this  is  likewise  true  in 
ordinary  catarrhal  anginas,  and  when  it  is  the  case  we  look 
for  the  explanation  either  in  some  constitutional  peculiarity  of 
the  patient,  or  in  some  peculiarity  of  the  inflammation  which 
is  not  evident,  or  in  some  undiscovered  complicating  inflam- 
mation or  in  some  pre-existing  and  complicating  constitutional 
poisoning  (malarial,  septic,  rheumatic,  etc.),  which  explana- 
tions are  equally  available  in  diphtheria. 

Third. — The  gravity  of  the  general  disease  varies  directly, 
as  a  general  rule,  in  proportion  to  the  extent  and  more  par- 
ticularly the  depth  of  the  local  affection.  While  this  propo- 
sition is  substantially  sustained  by  the  testimony  of  most 
observers  of  various  pathological  views,  it  is  maintained,  per 
contra,  by  some  excellent  authorities  that  the  correspon- 
dence referred  to  is  not  constant,  that  a  grave  constitu- 
tional disease  may  accompany  a  very  slight  local  affection, 
and  that  death  has  resulted  from  the  primary  poison  of  diph- 
theria in  cases  in  which  but  little  membrane  or  even  no  mem- 
brane has  existed. 

It  is  answered  that  such  cases  are  admittedly  so  rare  as  to 


102  diphtheria;   its  nature  and  treatment. 

be  exceptional,  and  that  there  is  great  liability  to  error  re- 
specting them.  To  the  sources  of  such  possible  error  already 
referred  to  in  defective  observation  and  in  the  occurrence  of 
diphtheritic  membrane  in  concealed  situations,  the  following 
may  be  added,  all  of  which  have  been  illustrated  in  my  own 
experience:  An  apparently  insignificant  membranous  patch 
Avhich  penetrates  deeply  may  result  in  profound  toxaemia,  while 
an  extensive  but  superficial  one  may  cause  scarcely  any.  A  triv- 
ial membranous  deposit  in  situations  favorable  to  absorption  (as 
for  instance  the  nares)  may  have  far  greater  constitutional  re- 
sults than  apparently  formidable  ones  in  different  anatomical 
relations  (as  the  convexity  of  enlarged  tonsils).  Again,  it  is  well 
known  that  epidemics  of  diphtheria  and  of  scarlatina  are  fre- 
quently associated,  and  that  this  association  has  been  a  fruit- 
ful source  of  confusion.  How  naturally  under  such  circum- 
stances might  a  death  from  malignant  scarlatina  without 
eruption  be  erroneously  attributed  to  diphtheria !  Finally,  it 
must  be  admitted  that  in  some  cases  of  diphtheria  the 
amount  of  false  membrane  is  disproportionately  slight  to  the 
septic  intoxication;  but  it  does  not  necessarily  follow  that 
the  latter  is  the  primary  fact.  It  is  more  reasonable  and 
more  in  accordance  with  many  analogies  in  surgical  and 
puerperal  sepsis  to  suppose  that  the  progress  of  the  dis- 
ease from  local  to  general  is  in  these  cases  either  from  some 
special  condition  or  tendenc}7-  pre-existing  in  the  patient,  or 
some  extraordinary  virulence  in  the  contagium,  or  perhaps 
from  both  circumstances  concurring,  more  rapid  than  in  or- 
dinary ones,  and  that  it  is  complicated  by  the  early  penetration 
into  the  system  of  septic  microbes. 

Fourth. — The  employment  of  proper  local  antiseptic  treat- 
ment does  in  many  cases  promptly  mitigate  or  quite  dispel 
constitutional  symptoms  previously  existing,  or,  if  early  em- 
ployed, prevent,  either  wholly  or  in  some  measure,  their  occur- 
rence, and  its  failures  to  accomplish  these  objects  occur  in 
exactly  those  cases  in  which  from  the  nature  of  things  it  can- 


THE    PRIMARY   NATURE    OF    DIPHTHERIA.  103 

not  be  or  in  which  it  is  not  efficiently  employed.  The  proof  of 
these  assertions  will  be  presented  in  the  chapter  on  treatment, 
to  which  the  reader  is  referred. 

While  the  foremost  place  in  the  treatment  of  diphtheria  is 
conceded  to  topical  measures  by  many  authorities  who  hold  to 
the  opposite  pathological  view  of  the  disease,  it  is  asserted  by 
some  as  an  argument  in  favor  of  that  view  (1)  that  local  treat- 
ment does  not  cut  short  the  disease,  and  (2)  that  it  does  not  in 
severe  cases  prevent  the  occurrence  of  constitutional  symp- 
toms. Even  if  the  first  assertion  be  true,  which  question  Avill 
be  elsewhere  considered,  the  argument  is  without  force,  since 
the  same  is  admittedly  true  in  the  case  of  gonorrhoea  and 
some  other  local  affections,  which  evidently  penetrate  the  liv- 
ing tissues  too  deeply  to  be  eradicable  by  disinfectants  which 
act  only  or  mainly  on  their  surface.  In  reference  to  the  second 
assertion  it  may  be  said  that  the  limitations  to  the  efficacy  of 
local  antiseptic  treatment  in  diphtheria,  being  such  as  is 
stated  above,  are  in  reality,  equally  with  its  successes,  illus- 
trative and  confirmatory  of  the  theory  of  the  primarily  local 
nature  of  the  disease. 

The  assertion 1  that  diphtheria  and  syphilis  are  analogous 
is  misleading,  since  the  analogy  is  at  most  only  a  partial  one; 
for  even  admitting  that  both  diseases  become  constitutional 
simultaneously  with  the  occurrence  of  the  primary  lesion 
(which  if  it  be  true  in  diphtheria  must  in  many  cases  be  so  in 
only  a  slight  and  unimportant  degree),  yet  they  differ  in  these 
two  important  respects:  There  is  not  in  syphilis  any  usual 
proportion  between  the  gravity  of  the  primary  and  the  second- 
ary affections,  and  the  secondary  disease  goes  on  independently 
of  the  primary  affection  and  uninfluenced  by  treatment  ap- 
plied to  it. 

^Sann^,  loc.  eit. 


CHAPTER  VI. 

SECONDARY   DIPHTHERIA. 

Secondary  Diphtheria  is  that  which  attacks  a  person 
who  is  already  suffering-  from  another  disease  of  which  the 
diphtheria  is  in  some  degree  the  result. 

Strictly  speaking,  a  large  proportion  of  all  cases  of  diph- 
theria are  secondary  rather  than  primary,  since,  as  has 
already  been  seen,  various  catarrhal  affections  of  the  mucous 
membranes  prepare  a  favorable  soil  for  the  insemination  of 
diphtheria.  The  term  secondary,  however,  is  more  usually 
applied  to  that  diphtheria  which  supervenes  upon  other  spe- 
cific diseases. 

Secondary  diphtheria  is  usually  subject  to  the  two  follow- 
ing laws :  (1)  It  manifests  itself  only  after  the  primary  dis- 
ease has  run  its  active  course,  or,  at  least,  after  its  intensity 
has  begun  to  abate.  (2)  It  occurs  on  those  mucous  mem- 
branes which  have  been  especially  affected,  and  thus  prepared 
for  its  invasion,  by  the  primary  disease. 

Secondary  diphtheria,  or  an  affection  resembling  diphthe- 
ria, undoubtedly  occurs  with  the  greatest  frequency  in  con- 
nection with  scarlatina.  It  is  a  mooted  question  whether  the 
pseudo-membranous  formation  which  so  frequently  appears  in 
the  course  of  this  disease  is  a  true  and  distinct  diphtheria,  or 
is  merely  a  product  of  the  scarlatinal  inflammation,  I  believe 
that  both  views  are  in  part  correct,  or,  in  other  words,  that 
there  is  a  very  common  diphtheroid  affection  which  is  merely 
a  part  of  scarlatinal  angina,  and  also  that  true  diphtheria 
very  often  supervenes  upon  scarlatina. 


SECONDARY    DIPHTHERIA.  •  105 

It  is  common  to  see  from  the  second  to  the  fifth  day  of 
scarlatina  the  previously  bright  red  mucous  membrane  of  the 
throat  become  coated  over  with  a  white  pellicle  which  is  in 
appearance  distinctive.  It  is  thin,  filmy,  uniform,  only  slightly 
elevated  above  the  surrounding  mucous  membrane,  is  not  in 
well-defined  sharply  limited  patches  as  in  the  case  of  true 
diphtheritic  membrane,  but  its  borders  shade  off  from  the 
unaffected  surface  by  an  almost  imperceptible  gradation.  It 
does  not  lie  loosely  upon  the  surface  of  the  mucous  membrane, 
nor  can  it  be  readily  detached  from  it,  but  is  closely  adherent 
to  it,  and  presents  to  the  eye  the  appearance  of  being  a  trans- 
formation in  its  most  superficial  epithelial  layers,  which  indeed 
it  probably  is.  It  is  often  quite  extensive,  covering  one  or 
both  tonsils,  one  or  both  faucial  arches,  the  anterior  surface 
of  the  soft  palate,  the  uvula,  and  in  some  cases  the  posterior 
wall  of  the  pharynx.  It  is  accompanied  with  a  more  or  less 
abundant  thin  or  glairy  muco-purulent  secretion.  It  usually 
persists  through  the  active  stage  of  the  disease  and  then  melts 
away  by  desquamation.  I  have  seen  this  form  of  affection 
in  many  cases.  It  has  never  produced  any  of  the  S3Tstemic 
conditions  which  are  peculiar  to  diphtheria,  nor  has  it  been 
followed  by  paralysis.  From  this  circumstance,  from  its  uni- 
form distinctiveness  of  character,  and  from  the  early  stage  of 
the  disease  at  which  it  appears,  I  regard  it  as  exclusively  a 
result  of  the  scarlatinal  inflammation. 

There  is  a  very  different  affection  which  usually  appears  at 
a  later  stage  of  the  disease — from  its  sixth  to  its  tenth  day  or 
even  later — when  its  intensity  has  begun  to  abate.  This 
commonly  commences  in  the  pharynx  with  the  usual  symp- 
toms and  appearances  of  faucial  diphtheria,  including  well- 
defined  patches  of  true  diphtheritic  membrane  of  varying 
thickness,  fcetor,  adenitis,  septicaemia,  etc.  It  has  a  great 
tendency  to  extend  over  the  regions  which  have  been  most 
affected  by  the  scarlatinal  inflammation,  especially  the  nasal 
passages,  the  Eustachian  tubes  and  the  middle  ear.     It  has 


106  diphtheria;   its  nature  and  treatment. 

even  in  some  cases  invaded  the  eye  by  way  of  the  lachrymal 
duct. 

I  have  seen  the  first-described  affection  very  common  in 
some  epidemics  of  scarlatina  at  times  when  diphtheria  was 
not  at  all  prevalent,  and,  on  the  other  hand,  have  seen  the  one 
last  referred  to  a  very  frequent  and  formidable  complication 
or  sequel  to  scarlatina  at  times  when  diphtheria  was  epidemic. 

True  diphtheria  may  supervene  upon  the  diphtheroid  form 
of  scarlatina,  the  whole  aspect  of  the  case  being1  thereby 
speedily  changed. 

It  will  be  seen  that  unless  the  distinction  which  has  now  in 
its  clinical  aspects  been  pointed  out  be  borne  in  mind,  compar- 
ative anatomical  observations  on  the  false  membranes  of  scar- 
latina and  of  diphtheria  can  have  little  value,  as  all  forms  of 
diphtheritic  metamorphosis  of  tissues  are  seen  in  connection 
with  scarlatina.  Yet  Heubner  would  seem  to  have  had  in 
view  the  diphtheroid  pseudo-membrane  which  I  first  described 
when  he  said,1  "  True  tissue-diphtheria  is  beautifully  illustrated 
and  developed  in  scarlatina,  and  differs  from  it  only  in  this 
respect,  that  in  the  latter  only  the  epithelium  and  superficial 
capillaries  are  affected,  while  in  the  former  both  mucous  and 
sub-mucous  layers,  including  the  blood-vessels,  are  implicated 
in  the  process  of  coagulation -necrosis." 

It  cannot  be  denied  that  true  diphtheria  does  in  exceptional 
cases  accompany  scarlatina  at  a  very  early  stage,  or  may 
even  be  the  prior  affection,  but  in  such  cases  the  diphtheria 
can  be  regarded  only  as  an  accidental  complication  of  the 
scarlatina.  In  the  records  of  many  epidemics,  especially  by 
the  earlier  writers,  as  we  have  seen  in  the  chapter  on  history, 
the  features  of  diphtheria  and  of  scarlatina  are  mingled  to- 
gether in  inextricable  confusion,  each  having  resulted  from 
the  contagion  of  the  other,  and  not  only  pharyngeal  and  nasal 
but  laryngeal  diphtheria  having  often  been  early  concomitants 
of  scarlatina.  Such  facts  can  only  be  explained  by  the  suppo- 
1  Die  Experinientelle  Diphtherie. 


SECONDARY   DIPHTHERIA.  107 

sition  that  unusually  intense  epidemics  of  each  disease  were 
concurrent. 

Diphtheria  in  following"  measles  conforms  to  the  two  general 
rules  above  stated,  in  appearing  as  the  eruption  and  acute 
symptoms  of  the  prior  disease  are  abating  (namely  after  the 
fifth  or  sixth  day  of  the  eruption)  and  in  being  localized  where 
its  principal  lesions  have  occurred.  Hence  it  has  been  found 
to  furnish  a  particularly  large  proportion  of  cases  of  the 
laryngeal  and  tracheal  affection.  For  this  reason  the  compli- 
cation is  an  especially  formidable  one,  the  mortality,  accord- 
ing to  some  statistics,  being  eighty  per  cent,     (Sanne.) 

Diphtheria  has  also  been  a  very  frequent  complication  in 
some  epidemics  of  small-pox,  and  has  shown  an  especial  ten- 
dency to  affect  the  larynx  and  trachea.1 

In  typhoid  fever,  diphtheria  rarely  occurs  before  the  end  of 
the  second  week.  It  frequently  affects  the  larynx,  but  owing 
to  the  obtunding  of  the  sensibilities  by  the  disease,  and  the  fact 
that  many  of  the  patients  are  adults,  it  often  fails  to  be  recog- 
nized during  life. 

In  accordance  with  the  second  law  above  referred  to,  sec- 
ondary diphtheria  is  sometimes  located  in  regions  which  are 
very  rarely  visited  by  primary  diphtheria.  Thus  diphtheria 
of  the  oesophagus  is  usually  consequent  upon  typhoid  fever, 
cholera,  measles,  scarlatina,  small-pox,  pulmonary  tuberculosis 
and  pyaemia,  and  that  of  the  gastric  mucous  membrane  upon 
scarlatina  and  small-pox.     (Ziegler.) 

1  Rtihle,  Die  Kehlkopf.  Krankheiten,  Berlin,  1861,  p.  247. 


CHAPTER  VII. 

DIPHTHERITIC   PARALYSIS. 

One  of  the  most  striking-  peculiarities  of  diphtheria  is  the 
frequency  with  which  it  is  followed  by  paralysis.  The  propor- 
tion of  cases  in  which  this  sequence  has  occurred  has  varied, 
according-  to  different  observers,  from  1.15  to  66  per  cent.  Of 
1382  cases  observed  by  Sanne,  eleven  per  cent,  were  followed 
by  paralysis.  In  view  of  the  liability  of  very  mild  cases  of 
paralysis  to  be  unrecognized,  the  estimate  of  Gowers1  of 
twenty-five  per  cent,  of  all  cases  is  perhaps  not  excessive. 

Diphtheritic  paralysis  is  usually  a  sequela,  for,  while  it  oc- 
casionally appears  early  in  the  course  of  the  primary  disease, 
yet  in  by  far  the  greater  number  of  cases  it  is  first  manifested 
in  the  second  or  third  week,  and  has  occurred  as  late  as  the 
fortieth  day  after  the  disappearance  of  the  local  symptoms. 
It  follows  the  mildest  cases  as  well  as  the  most  severe  ones. 
According  to  the  statistics  of  Landouzy 2  the  tendency  to  its 
occurrence  is  very  slight  in  infants  and  increases  with  age.  It 
has  one  usual  starting-point,  the  soft  palate,  to  which  in  a 
large  proportion  of  cases  it  is  limited.  When  it  invades  other 
parts  successively  there  is  a  certain  order  of  progression 
which,  as  a  rule  (though  subject  to  many  exceptions),  it  ob- 
serves. It  is,  in  the  great  majority  of  cases,  a  paresis  rather 
than  a  complete  paralysis.  It  is,  as  a  rule,  of  comparatively 
brief  duration.  Its  termination,  with  relatively  few  excep- 
tions, is  in  complete  recovery. 

Paralysis  of  the  soft  palate  and  pharynx  first  manifests 

1 "  Diseases  of  the  Nervous  System,"  p.  1221. 

2 "  Des  Paralysies  dans  les  maladies  aigues,"  Paris,  1880. 


DIPHTHERITIC    PARALYSIS.  109 

itself  by  modifications  in  the  voice.  Articulation,  especially  of 
the  palatal  consonants  and  vowels,  is  difficult  or  impossible. 
Speech  may  present  all  grades  of  imperfection,  from  a  slight 
nasal  twang  to  complete  unintelligibility.  Deglutition  is  also 
interfered  with  in  various  degrees.  In  the  least  degree  there 
is  experienced  a  slight  slowness  or  clumsiness  in  the  act  of 
swallowing.  In  a  greater  degree,  liquids  are  regurgitated 
through  the  nose.  Solids  are  swallowed  more  easily,  but  even 
they  in  bad  cases  give  much  trouble,  missing  the  oesophagus 
to  enter  the  larynx  or  to  remain  in  the  naso-pharyngeal  cav- 
ity. Small  portions  usually  cause  more  inconvenience  than 
larger  quantities.  This  interference  with  swallowing  in  some 
cases  makes  the  taking  of  necessary  nourishment  a  matter  of 
extreme  difficulty.  Expectoration,  or  the  expulsion  of  mucus 
from  the  throat  and  nasal  passages,  is  in  like  manner  rendered 
difficult  or  impossible. 

If  the  mouth  be  opened  the  soft  palate  is  seen  to  hang  re- 
laxed and  motionless.  When  the  paralysis  is  unilateral  it  is 
drawn  toward  the  healthy  side.  It  has  partially  or  wholly 
lost  its  sensibility  and  does  not  respond  to,  tickling  or  irrita- 
tion by  the  usual  reflex  movements.  The  muscles  of  the 
tongue,  lips,  and  face  are  sometimes  affected. 

Disturbances  of  vision  are  of  frequent  occurrence.  They 
usually  appear  soon  after  the  commencement  of  the  palatal 
paralysis,  but  in  rare  cases  simultaneously  with  it  or  even 
before  it.  The  most  common  form  is  asthenopia.  There  is 
difficulty  in  reading  fine  print  or  distinguishing  other  small 
objects.  Efforts  to  do  so  are  quickly  followed  by  fatigue  and 
blurring  or  flashes  of  light  before  the  eyes.  The  vision  of  dis- 
tant objects  is  not  usually  impaired.  These  symptoms  are 
due,  according  to  the  researches  of  Donders,1  mainly  to  de- 
fective accommodation  from  paresis  of  the  ciliary  muscles.  In 
some  cases  there  are  diplopia,  vertigo  and  strabismus  of  one 
or  both  eyes,  from  the  involvement  of  the  oculo-motor  mus- 
1  British  Med.  Jour.,  May  12th,  1877,  p.  505. 


110  diphtheria;  its  nature  and  treatment. 

cles,  and  more  rarely  ptosis,  from  implication  of  the  levator 
palpebral  superioris. 

Next  in  order  of  occurrence  are  paralyses  of  the  muscles  of 
the  extremities,  those  of  the  lower  extremities  being-  usually 
the  first,  and  sometimes  the  only  ones,  to  be  affected.  The 
affection  commonly  begins  with  disturbances  of  sensation, 
such  as  feelings  of  coldness,  numbness,  tingling  or  sharp 
pains.  Various  degrees  of  feebleness  in  some  or  all  of  the 
muscles  concerned  in  locomotion  are  next  experienced.  The 
ground  often  feels  soft  and  yielding  from  impairment  of  the 
muscular  sense.  Cutaneous  sensibility  is  sometimes  abolished, 
especially  in  the  soles  of  the  feet.  Anaesthesia  is  sometimes 
accompanied  with  analgesia,  which  may  be  general  in  the  ex- 
tremity affected  or  confined  to  limited  areas.  Sometimes  the 
symptoms  are  those  of  ataxia.  The  movements  are  incoordi- 
nate and  the  patient  cannot  walk  with  his  eyes  closed.  The 
affection  of  the  muscles  rarely  exceeds  a  greater  or  less  degree 
of  paresis,  and  is  often,  as  in  other  situations,  limited  to  par- 
ticular muscles  or  groups  of  muscles,  but  in  rare  cases  abso- 
lute paralysis  of  the  lower  extremities  ensues.  In  proportion 
to  the  degree  and  duration  of  the  paralysis  there  are  flabbi- 
ness  and  a  tendency  to  atrophy  of  the  muscles. 

A  similar  order  of  symptoms  may  occur  in  the  upper  ex- 
tremities. Tactile  sense  in  the  fingers  is  diminished  or  lost. 
The  affection  is  more  usually  partial  and  limited  to  certain 
muscles,  causing  tremor  or  choreic  movements,  and  feebleness, 
clumsiness  and  uncertainty  in  the  use  of  the  hands  and  arms. 
In  rare  cases  the  paralysis  here  also  becomes  complete. 

Diphtheritic  paralysis  in  the  extremities  is  most  usually 
S3Tmmetrical,  though  often  somewhat  unequal  in  the  two  sides. 
Its  absolute  limitation  to  one  side  is  very  rare,  though  not 
altogether  unknown. 

Diphtheritic  paralysis  of  the  muscles  of  the  larynx  seldom 
occurs  alone  or  in  connection  with  that  of  the  pharynx  merely, 
but  usually  appears  only  in  the  course  of  more  general  paral- 


DIPHTHERITIC    PARALYSIS.  Ill 

ysis.  It  may  be  limited  to  one  muscle  or  may  be  general.  Its 
presence  may  be  recognized  by  modifications  in  the  quality  of 
the  voice,  varying-,  according  to  the  extent  and  degree  of  the 
affection,  from  slight  roughness  or  loss  of  resonance  to  abso 
lute  aphonia.  Tranquil  respiration  is  not  seriously  interfered 
with,  but  coughing,  forcible  expiration,  and  "holding  the 
breath"  are  rendered  difficult.  Loss  of  sensibility  in  the 
laryngeal  mucous  membrane  sometimes  accompanies  the 
motor  paralysis.  From  this  cause  portions  of  food  have  en- 
tered the  larynx  unperceived  by  the  patient  and  have  caused 
death  by  suffocation.  This  accident  may  also  result  from 
sensory  and  muscular  paralysis  of  the  epiglottis. 

On  laryngoscopic  examination  it  is  found  that  one  or  both 
vocal  cords  have  lost  in  part  or  wholly  their  motility.  When 
only  one  muscle  is  affected  the  position  of  the  vocal  cord  is 
fixed  by  the  antagonistic  action  of  the  non-paralyzed  muscles. 
When  the  paralysis  of  the  laryngeal  muscles  is  general,  the 
vocal  cords  are  motionless  midway  between  the  positions  of 
phonation  and  of  respiration,  as  in  the  cadaver. 

Paralysis  of  the  muscles  of  the  neck  and  trunk  is  usually 
one  of  the  latest  developments  in  general  diphtheritic  paraly- 
sis. When  the  former  are  seriously  affected  the  patient  is 
unable  to  raise  or  hold  up  or  turn  the  head,  which  droops  help- 
lessly. When  the  latter  are  paralyzed  he  is  similarly  deprived 
of  the  power  to  hold  the  body  upright,  or  even  to  turn  in  bed. 
Implication  of  the  intercostal  muscles  causes  serious  embar- 
rassment to  respiration.  When  the  diaphragm  is  also  in- 
volved, the  shallowness  and  difficulty  of  breathing  are  greatly 
increased,  and  in  proportion  to  the  degree  of  the  paralysis 
there  are  cyanosis  and  liability  to  death  from  asphyxia. 

The  heart  is  also  affected  by  diphtheritic  paralysis,  and  to 
this  fact  is  due  by  far  the  greatest  number  of  its  fatal  results. 
The  time  at  which  this  affection  occurs  varies  widely.  It  some- 
times takes  place  in  the  second  or  third  week  of  the  primary 
disease,  or,  in  rare  cases,  even  earlier,  and,  on  the  other  hand, 


112  DIPHTHERIA;    ITS    NATURE    AND    TREATMENT. 

is  not  infrequent  in  advanced  convalescence,  and  is  usual  in 
the  course  of  general  diphtheritic  paralysis. 

Its  severity  and  fatality  are,  as  a  general  (though  not  inva- 
riahle)  rule,  greatest  when  it  occurs  early.  Even  then  it  has 
usually  been  preceded  by  palatal  or  pharyngeal  paralysis, 
though  it  is  not  impossible  that  the  heart  should  be  the  part 
first  affected.  Its  onset  in  this  form  is  usually  sudden.  It  is 
often  attended  with  a  rigor  or  a  sensation  of  chilliness.  It  is 
frequently  preceded  or  accompanied  with  symptoms  of  gas- 
tric disturbance  and  failure  of  digestion,  such  as  nausea,  ano- 
rexia, etc.  There  is  a  sudden  accession  of  dyspnoea  and  precor- 
dial oppression.  The  countenance  expresses  distress  and 
alarm,  and  its  hue  is  pale  or  cyanotic.  The  surface,  especially 
of  the  extremities,  is  cold.  The  pulse  is  weak,  fluttering,  in- 
termittent and  variable,  the  heart-sounds  muffled,  confused 
and  irregular.  Death  may  ensue  quickly,  or  only  after  a 
number  of  hours,  or  the  attack  may  be  partially  recovered 
from  only  to  return  again,  or  (too  rarely)  the  recover}7  may 
be  complete  and  permanent.  Cadet  de  Gassicourt  records 
only  one  recovery  in  fifteen  such  cases. 

As  it  occurs  at  a  later  period,  diphtheritic  paralysis  of  the 
heart,  like  that  of  other  organs,  varies  from  a  slight  and 
transient  paresis  to  a  suddenly  fatal  cessation  of  function.  In 
the  whole  number  of  cases  the  fatal  results  are  doubtless  f«wer 
than  the  recoveries. 

During  the  continuance  of  cardiac  paralysis  there  is  great 
liability  to  an  aggravation  of  the  condition  by  exertion,  even 
the  slightest  effort  having  in  many  cases  been  followed  by  a 
fatal  result  and  in  others  by  alarming  but  transient  symp- 
toms of  heart-failure.  An  interesting  case  of  a  practicing 
physician  of  this  city,  as  related  by  himself,  is  published  by 
Dr.  A.  D.  Rockwell.1  In  this  case  "cardiac  difficulty,"  paresis 
of  soft  palate,  pharynx  and  larynx,  of  ciliary  muscles,  of  upper 
extremities,  of  lower  extremities  and  of  bowels,  appeared  in 
1 "  Medical  and  Surgical  Electricity,"  p.  629. 


DIPHTHERITIC    PARALYSIS.  113 

the  order  mentioned,  beginning  about  the  third  week  after  the 
disappearance  of  the  diphtheritic  patches  and  ceasing  in  the 
sixteenth  week,  except  that  slight  cardiac  feebleness  remained 
for  fifteen  months.  The  cardiac  difficulty  mentioned  was  in- 
dicated by  a  very  feeble,  soft,  slow  pulse  averaging  sixty  per 
minute.  "On  one  occasion,  immediately  following  special  ex- 
ertion, the  pulse  quickly  rose  to  160  and  as  quickly  fell  to  32 
per  minute,  resulting  in  an  attack  of  angina  pectoris,  which 
persisted  for  nearly  three  hours.  This  sudden  fluctuation  of 
the  pulse  was  most  alarming,  and  caused  apprehension  of  im- 
mediate dissolution."  It  is  also  stated  that  the  symptoms, 
not  only  of  the  cardiac  but  of  the  other  paralysis,  "  were  in- 
variably increased  by  the  slightest  exercise." 

The  walls  of  the  intestines  and  of  the  bladder  and  also  their 
sphincters  are  occasionally  affected  with  diphtheritic  paraly- 
sis, producing  in  the  former  case  retention  of  their  contents, 
and  in  the  latter  involuntary  fecal  movements  or  incontinence 
of  urine.  Anaphrodisia  and  impotence  are  not  infrequent 
sequelae.  Paralyses  of  the  special  senses,  such  as  temporary 
amaurosis,  deafness,  and  impairment  in  various  degrees  of 
taste  and  smell,  have  been  observed.  Anaesthesias  and  dyses- 
thesias have  also  occurred  without  accompanying  motor  pa- 
ralysis. 

While  the  order  of  occurrence  of  the  various  localizations 
of  diphtheritic  paralysis  which  has  now  been  indicated  is  a 
usual  one,  it  is  far  from  being  invariable,  and  they  may  take 
place  successively  in  any  order  whatever,  or  any  number  of 
them  may  be  present  at  the  same  time.  Thus,  in  the  case  of  a 
physician,  reported  by  himself,1  the  order  of  events  was  as  fol- 
lows: Pains  in  axilla,  arms  and  hands,:  motor  paralysis  of 
lower  extremities;  loss  of  sensation  in  limbs  and  trunk;  sen- 
sory and  motor  paralysis  in  upper  extremities;  loss  of  sensa- 
tion in  mouth,  tongue  and  portions  of  face;  paralysis  of  soft 
palate;   dimness   of  vision;   increase   of  motor   and   sensory 

1  Dr.  Reed,  Boston  Med.  and  Surg.  Journal,  July  13th,  1876. 
8 


114  diphtheria;  its  nature  axd  treatment. 

paralysis  in  arms  and  hands;  paralysis  of  bladder;   loss  of 
power  of  erection;  paralysis  of  interosseous  muscles. 

The  duration  of  diphtheritic  paralysis  is  generally  in  pro- 
portion to  its  severity.  I  have  seen  a  paresis  of  the  soft  palate 
entirely  disappear  within  eight  days  from  its  commencement, 
and  from  two  to  six  weeks  is  a  frequent  duration.  More  gen- 
eral cases  may  last  for  as  many  months,  and  in  rare  instances 
some  of  the  symptoms  persist  for  years. 

The  small  proportion  of  cases  which  terminate  fatally  do 
so  from  inanition  caused  by  difficulty  in  swallowing,  from  the 
effects  of  the  entrance  of  foreign  bodies  into  the  air-passages 
in  pharyngeal  and  laryngeal  paralysis,  and  from  pulmonary 
affections  produced  or  aggravated  by  that  paralysis,  from 
asphyxia  in  paralysis  of  the  respiratory  muscles  and  from 
heart -failure  in  cardiac  paralysis. 

The  reaction  to  electricity  in  many  cases  of  diphtheritic 
paralysis  is  not  perceptibly  altered.  In  severe  ones  farado- 
muscular  contractility  is  usually  diminished,  while  galvano- 
muscular  contractility  continues  normal  or  is  exaggerated. 
In  grave  cases  of  long  duration,  in  which  the  muscles  are 
atrophied,  their  contractility  under  the  galvanic  current  is 
diminished  or  lost.  Thus  the  reactions  to  electricity  in  diph- 
theritic paralysis  are  generally  those  of  peripheral  nerve  de- 
generation, as  has  been  pointed  out  by  Ziemssen x  and  many 
subsecpient  writers. 

The  onset  of  diphtheritic  paralysis  is  usually,  though  not  in- 
variably, accompanied  by  the  loss  of  the  knee-jerk.  The  re- 
markable fact  was  discovered  by  Bernhardt 2  that  the  knee- 
jerk  is  abolished,  not  only  in  actual  diphtheritic  paralysis,  but 
in  a  large  proportion  of  all  cases  of  convalescence  from  diph- 
theria that  are  unattended  by  recognizable  paralysis.  In 
twenty-one  such  cases  examined  by  him  the  knee-jerk  contin- 
ued on  both  sides  in  seven,  but  was  absent  on  one  side  in  one, 


•Berl.  Klin.  Wochenschrift,  18(56,  Nos.  43  and  44. 
2Virchow'sArehiv.,  1885,  Bd.  99,  p.  293. 


DIPHTHERITIC    PARALYSIS.  115 

and  on  both  sides  in  thirteen,  the  loss  occurring"  in  two-thirds 
of  his  cases.  This  observation  has  since  been  abundantly  con- 
firmed. The  abolition  of  the  knee-jerk  usually  occurs  in  the 
latter  part  of  the  first  month  after  the  onset  of  the  primary 
disease,  or  in  the  course  of  the  second  month,  and  continues 
for  four  or  five  months.  Its  disappearance  is  frequently  pre- 
ceded by  its  temporary  exaggeration.  Its  return  is  at  first 
unilateral  and  is  gradual,  there  being  alternations  of  its  occur- 
rence and  its  non-occurrence.  The  knee-jerk  may  be  present 
in  post-diphtheritic  ataxia,  and  may  be  absent  when  there  is 
no  ataxia. 

Loss  of  knee-jerk  also  occurs  at  an  early  stage  of  some 
cases  of  diphtheria.  Dr.  R.  L.  McDonnell J  states  that  in  eigh- 
teen cases  of  diphtheria  in  the  Montreal  General  Hospital, 
knee-jerk  was  absent  at  the  time  of  admission  in  10,  and  pres- 
ent in  8. 

Albuminuria  is  a  frequent,  but  not  a  constant,  accompani- 
ment in  grave  cases  of  diphtheritic  paralysis.  Thus  of  sixteen 
fatal  cases  described  by  Abercrombie,  albuminuria  occurred 
in  one  fourth. 

The  anatomical  changes  which  have  been  observed  in  fatal 
cases  of  diphtheritic  paralysis  have  been  elsewhere  described 
(page  65).  They  consist  in  inflammatory  and  atrophic 
changes  in  the  gray  matter  of  the  anterior  horns  of  the  spinal 
cord;  inflammatory  or  degenerative  lesions  of  peripheral 
nerves;  changes  in  the  vascular  system  and  its  contents,  and 
atrophic  changes  in  muscles. 

The  changes  in  the  nerves  are  in  the  greater  number  of 
cases  primarily  and  mainly  in  the  nerve-elements  themselves 
rather  than  in  the  investing  or  interstitial  tissues.  They  are 
characteristic  of  "  parenchymatous  neuritis,"  a  degenerative 
condition  which  may  begin  at  any  point  in  the  course  of  a 
nerve,  or  may  be  consecutive  to  lesions  in  the  spinal  nerve- 

1  Medical  News,  October  15,  1887,  p.  448. 


116  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

cells.  It  extends  downward  in  the  course  of  the  nerve  from  its 
point  of  commencement,  but  not  upward. 

In  other  cases  inflammatory  changes  in  the  interstitial 
elements  of  the  nerves  predominate.  Interstitial  neuritis,  un- 
like the  parenchymatous,  may  extend  upward  in  the  nerve. 
Its  occurrence  in  the  palatine  nerves  may  he  due  to  the  prox^ 
imity  of  their  terminal  filaments  to  the  seat  of  the  primary 
diphtheritic  inflammation  and  their  consequent  exposure  to 
the  direct  action  of  the  poison  there  evolved.  That  this  is  the 
case  in  some  of  the  instances  in  which  the  diphtheritic  inflam- 
mation in  the  soft  palate  is  intense  and  the  paralysis  in  that 
situation  occurs  early  is  not  improbable.  That  the  usual  com- 
mencement of  diphtheritic  paralysis  in  the  soft  palate  cannot 
in  all  cases  be  thus  explained  is  shown  by  the  facts  of  patho- 
logical anatomy  above  referred  to,  and  also  by  the  clinical 
facts  that  paralysis  often  occurs  when  the  pharyngeal  inflam- 
ation  has  been  extremely  slight  and  fails  to  occur  when  it 
has  been  intense,  and  that  palatal  paralysis  has  appeared  in 
some  cases  in  which  there  has  been  no  sore  throat,  the  diph- 
theritic inflammation  having  occurred  on  wounds,  etc.  in  re- 
mote situations,  and  that  paralysis  following  pharyngeal 
diphtheria  sometimes  commences  in  remote  parts  of  the  body. 
Yet  such  cases  must  be  regarded  as  exceptional,  the  general 
fact  being  that  diphtheritic  paralysis  usually  commences  in 
what  may  be  called  regional  proximity  to  the  site  of  the  origi- 
nal disease.  Trousseau,  after  referring  to  several  of  the  cases 
just  alluded  to,  adds,  "  Generally,  however,  where  the  paraly- 
sis is  consecutive  to  cutaneous  diphtheria  it  commences  in  the 
extremities;"  and  many  recorded  cases  support  this  state- 
ment. 

It  must  be  remembered  that  the  anatomical  lesions  above 
referred  to,  occurred  in  fatal  cases.  That  in  ordinary  cases 
they  are  far  less  grave  is  evident  from  the  clinical  fact  that 
recovery  in  them  is  usualty  speedy  and  almost  always  com- 
plete.   Yet  it  is  reasonable  to  suppose  that  the  difference  is 


DIPHTHERITIC    PARALYSIS.  117 

rather  in  degree  than  in  kind,  the  disturbance  in  the  nutrition 
of  the  nerves  affected  varying-  throug-h  all  gradations  from 
that  which  is  so  slight  as  to  be  manifested  only  in  a  transient 
and  scarcely  perceptible  impairment  of  function  to  that  which 
is  destructive  and  fatal.  The  g-enerally  accepted  view  of  the 
pathology  of  the  most  usual  forms  of  diphtheritic  paralysis  is 
stated  by  Dr.  T.  Buzzard  1  as  follows :  "  I  do  not  think  that 
with  the  clinical  evidence  before  us  we  are  justified  in  saying- 
that  diphtheritic  paralysis  in  its  ordinary  form,  passing  to 
complete  recovery,  is  dependent  upon  an  affection  of  the  spinal 
cord.  It  is,  in  my  opinion,  more  reasonable  to  conclude  that 
in  this  disease  we  have  usually  to  do  with  peripheral  neuritis 
of  very  varying-  severity,  which  in  the  mildest  cases  is  proba- 
bly represented  by  a  mere  transitory  hyperaemia  with  effusion 
in  the  interstitial  element." 

The  precise  manner  in  which  diphtheria  causes  diphthe- 
ritic paralysis  has  not  yet  been  demonstrated.  It  has  been 
held  by  many  that  the  disturbance  of  nutrition  in  the  nervous 
system  which  underlies  the  paralysis  is  wholly  or  mainly  due 
to  the  anaemia  which  is  a  striking  characteristic  of  convales- 
cence from  diphtheria.  This  view  is  neg-atived  by  the  fact 
that  paralysis  often  occurs  in  cases  in  which  ansemia  is  slight- 
est and  fails  to  occur  in  those  in  which  it  is  most  marked,  and 
moreover  that  in  other  conditions  in  which  ansemia  is  equally 
profound  the  sj^mptoms  which  are  peculiar  to  diphtheritic 
paralysis  are  unknown. 

A  consideration  of  the  pathological  and  clinical  facts  which 
have  now  been  referred  to,  in  connection  with  what  has  else- 
where been  stated  in  reference  to  the  pathology  of  diphtheria, 
can  leave  no  reasonable  doubt  that  diphtheritic  paralysis  is 
due  to  the  action  upon  the  nervous  system  of  a  poison,  the 
presence  of  which  in  the  org-anism  is  in  some  way  the  result  of 
diphtheria.  It  is  also  highly  probable  that  that  poison  be- 
longs to  the  class  of  ptomaines.  But  the  exact  nature  of  that 
1  Lancet,  Dec.  19,  1885,  p.  1128. 


118  diphthekia;   its  nature  and  treatment. 

poison  and  of  its  action  upon  the  nervous  system  is  involved 
in  no  little  obscurity.  It  has  been  assumed  by  some  that  it  is 
the  diphtheritic  virus  itself;  but  opposed  to  that  view  are  the 
facts  that  paralysis  follows  only  a  small  proportion  of  all 
cases  of  diphtheria,  and  that  the  probability  of  its  occurrence 
and  its  severity  when  it  occurs  bear  no  relation  whatever  to 
the  character  of  the  primary  disease,  and  also  that  in  some 
cases  it  commences  weeks  after  the  cessation  of  the  primary 
disease,  and  only  reaches  its  height  several  months  later. 
The  loss  of  the  knee-jerk  is  also  without  known  definite  rela- 
tion to  the  character  of  the  disease  and  to  the  subsequent 
occurrence  of  paralysis.  Many  circumstances  favor  the  hy- 
pothesis that  the  cause  of  diphtheritic  paralysis  is  a  distinct 
nerve-poison  concomitant  to  or  resultant  from  the  diphtheritic 
virus,  and  generated  in  the  system  along-  with  it  or  subse- 
quently during-  the  period  of  convalescence  in  some  cases,  but 
not  in  others.  In  support  of  this  theory  the  following  remark- 
able facts  are  cited  by  Gowers 1  from  Boissarie :  "  In  a  certain 
district  of  Paris  there  occurred  a  series  of  cases  of  severe 
diphtheria,  and  at  the  same  time  a  series  of  cases  of  paraly- 
sis of  the  palate,  eyes,  limbs,  heart,  etc.  perfectly  like  that 
which  occurs  after  diphtheria,  and  accompanied  by  albuminuria. 
The  remarkable  fact  is  that  in  these  cases  of  primary  pals3r 
there  was  no  history  of  preceding  sore-throat,  and  in  several 
of  the  cases  distinct  diphtheria  followed  the  paralysis,  which 
lessened  during  the  throat-affection.  Some  of  the  cases  of 
primary  palsy  seemed  to  arise  distinctly  by  infection." 

Dr.  W.  H.  Thomson  says:2  "Our  knowledge  of  the  action 
of  the  micro-organisms  is  sufficiently  advanced  now  for  us  to 
know  that  some  of  them  evidently  cause  disease  by  generating 
definite  poisons  or  ptomaines,  which  are  absorbable  into  the 
blood,  and  then  act  there  just  as  other  poisons  act,  some  of 
them  as  even  arsenic  does,  causing  multiple  neuritis  of  a  dis- 
seminated  and  yet  selective  kind It    becomes  quite 

1  Op.  cit.,  p.  1233.  2  Loc.  cit. 


DIPHTHERITIC    PARALYSIS.  119 

conceivable  to  infer  that  the  working-  of  the  diphtheritic  or- 
ganism may  prepare,  in  certain  cases,  the  way  for  some  subse- 
quent process  in  the  body  by  another  organism,  when  the 
conditions  for  its  growth  have  been  fulfilled  by  the  antecedent 
presence  of  the  diphtheritic  agent,  and  that  it  is  during  this 
subsequent  process  that  the  poison  which  works  such  mischief 
on  the  nervous  mechanism  is  produced." 

The  probability  that  this  poison  causes  paralysis  in  most 
cases  by  producing  trophic  disturbances  of  very  various  de- 
gree in  the  peripheral  nerves  has  already  been  referred  to. 
That  in  some  cases  it  has  a  direct  and  powerful  paralyzant 
effect  upon  the  nerves  by  arresting  their  function  without  pro- 
ducing any  appreciable  structural  lesion  has  been  shown  in 
various  autopsies.  That  this  may  probably  be  its  action  in 
cases  of  early  and  sudden  heart-failure,  and  also  in  other 
forms  of  early  and  transient  diphtheritic  paralysis  has  recently 
been  shown  with  much  force  of  reasoning  by  Dr.  J.  Lewis 
Smith,1  the  principal  arguments  adduced  being  the  following : 
Ptomaines  spring  into  existence  suddenly  and  unexpectedly 
under  favoring  conditions.  Cases  occur  in  which  carefully  con- 
ducted microscopic  examinations  reveal  an  apparently  normal 
state  of  the  nerves  supplying  the  paralyzed  part,  and  of  that 
part  of  the  cerebro-spinal  axis  from  which  the  nerves  arise, 
and  also,  in  cases  of  heart-failure,  of  the  heart  itself.  Palatal 
paralysis  sometimes  occurs  as  early  as  the  second  or  third 
day  of  diphtheria,  and  loss  of  the  tendon-reflex  as  early  as  the 
first  day;  and  it  seems  improbable  that  a  peripheral  neuritis 
or  anatomical  changes  in  the  cerebro-spinal  axis,  such  as  to 
cause  paralysis,  should  occur  at  so  early  a  date.  In  its  com- 
mencement diphtheritic  paralysis  often  suddenty  shifts  from 
one  group  of  muscles  to  another,  or  there  is  a  sudden  recovery 
from  it  on  one  day,  and  a  recurrence  of  it  on  the  next;  which 
would  seem  impossible  if  it  resulted  from  degenerative  nerve- 

1 "  Sudden  Heart-Failure  in  Diphtheria ;  its  Pathology  and  Treat- 
ment," Medical  News,  Nov.  10,  1888,  p.  536. 


120  diphtheria;   its  nature  and  treatment. 

changes,  either  central  or  peripheral.  The  incomplete  or  par- 
tial character  of  the  degenerative  changes  in  peripheral  nerves 
which  have  been  observed  by  some  microscopists  would  hardly 
account  for  the  complete  paralysis  which  often  exists,  for  in- 
stance, in  the  velum  palati. 

The  various  facts  which  have  now  been  referred  to  seem  to 
warrant  the  following  general  conclusions:  1.  "It  may  be 
positively  asserted  that  diphtheritic  paralysis  does  not  in 
every  case  depend  on  one  and  the  same  cause "  (Jacobi).  2. 
The  early  forms  of  the  affection  are  probably  due  mainly  to  a 
direct  inhibitory  effect  upon  nervous  function  either  of  the 
diphtheritic  poison  or  of  some  other  poison  which  is  often,  but 
not  necessarily,  associated  with  it.  3.  The  later  forms  of  the 
affection  result  from  pathological  changes  in  the  nervous  sys- 
tem, the  most  usual  form  of  which  is  parenchymatous  or  degen- 
erative peripheral  neuritis — these  changes  being  initiated  by 
the  diphtheritic  poison  or  poisons  and  favored  by  the  impover- 
ished condition  of  the  blood. 


CHAPTER  VIII. 

DIAGNOSIS. 

The  recognition  of  grave  forms  of  diphtheria,  when  fully 
developed,  is  usually  easy ;  but  then  the  recognition  is  often  too 
late.  It  is  the  earlier  stages  and  milder  forms  of  the  disease 
which  need  to  be  intelligently  discriminated  from  certain  affec- 
tions which  often  hear  an  astonishingly  close  resemblance  to 
them ;  and  this  discrimination,  its  essential  principles  being 
understood,  is  in  most  cases  not  difficult. 

The  first  essential  in  this  diagnosis  is  complete  and  accu- 
rate observation. 

As  ou"  patients  are  mostly  children,  the  laryngoscopic  and 
rhinoscopic  mirrors  are  for  obvious  reasons  not  usually  very 
available,  nor  are  they  generally  necessary,  though  in  some 
cases,  especially  in  older  patients,  they  may  give  valuable  in- 
formation. 

The  patient  should  be  placed  for  examination  directly  in 
front  of  a  window  or  a  good  artificial  light — if  a  young  child, 
on  the  lap  of  his  nurse.  Thorough  inspection  of  the  throat  is 
now  in  most  cases  easy.  But  some  young  children  will  oppose 
the  operation.  When  this  disposition  is  manifested  the  nurse 
should  secure  the  patient's  hands  while  some  other  person 
stands  behind  him  and  holds  his  head  between  the  palms  of 
the  hands.  Then,  if  the  lips  and  teeth  are  compressed,  the 
tongue-depressor  (a  smooth  spoon-handle  is  one  of  the  best) 
should  not  be  thrust  forcibly  in,  but  held  in  readiness  await- 
ing the  opportunity  which  the  child  will  soon  give.  It  is  then 
slipped  deftly  between  the  teeth  and  well  back  into  the  mouth 
along  the  dorsum  of  the  tongue,  when  gentle  pressure  down- 


122  diphtheria;   its  nature  and  treatment. 

wards  will  cause  the  child  to  open  his  mouth  and  give  a  view 
of  the  throat.  The  conformation  of  the  mouth  and  throat  is 
so  different  in  different  persons  that  it  is  now  and  then  a 
matter  of  some  difficulty  to  obtain  a  satisfactory  view  of  the 
throat,  especially  if  the  patient  resists  or  is  inclined  to  vomit. 
In  such  cases  some  perseverance  may  be  necessary.  Repeated 
attempts  with  a  little  interval  between  them  are  less  likely  to 
excite  vomiting"  than  retaining  the  tongue-depressor  in  posi- 
tion .too  long  at  one  time.  The  very  act  of  "gagging"  will 
throw  the  tonsils  forward,  giving  a  view  of  their  posterior 
surface. 

The  throat  having  been  thus  thoroughly  inspected,  perhaps 
only  redness  and  more  or  less  swelling  are  observed.  Do  these 
denote  the  catarrhal  or  ante-membranous  stage  of  diphtheria 
or  some  other  inflammation  of  the  throat  ?  The  probability 
of  its  being  the  former  will  be  favored  by  the  fact  of  previous 
exposure  to  contagion  or  the  presence  of  an  epidemic,  and  by 
certain  characteristics  of  the  throat-inflammation,  especially 
a  certain  intensity  and  a  somewhat  abrupt  limitation  to  a 
particular  location,  as  one  tonsil  or  one  faucial  pillar  or  a  por- 
tion of  the  soft-palate;  but  it  is  only  occasionally  that  this 
evidence  is  very  significant.  Other  forms  of  throat-inflamma- 
tion, as  the  follicular,  are  often  one-sided,  and  I  have  seen  the 
aspect  of  the  throat  in  diphtheria  a  few  hours  before  the  ap- 
pearance of  membrane  in  no  way  distinguishable  from  that  of 
many  ordinary  sore-throats.  Hence  a  positive  diagnosis  of 
diphtheria  can  but  rarely  be  made  at  this  stage. 

But  suppose  that  we  see  on  the  inflamed  mucous  mem- 
brane of  the  throat  whitish,  yellowish  or  grayish  appearances 
which  at  the  first  view  more  or  less  resemble  false  membrane. 
It  is  safe  to  say  that  a  diagnosis  of  diphtheria  or  of  "  diphthe- 
ritic sore-throat "  based  simply  on  them  would  in  the  large 
majority  of  cases  be  erroneous. 

It  may  be  remarked  in  passing,  that  the  phrase,  diphthe- 
ritic sore-throat,  may  indeed  have  a  legitimate  use  to  convey 


DIAGNOSIS.  123 

a  definite  and  well -understood  meaning-;  but  it  lias  far  too 
commonly  been  vaguely  and  indiscriminately  applied  in  the 
absence  of  a  positive  diagnosis  to  various  mild  diphtheroid 
affections,  most  of  which  are,  in  no  true  sense  of  the  word, 
diphtheritic. 

The  one  pathognomonic  sign  of  diphtheria  is  diphtheritic 
false  membrane.  The  existence  of  diphtheria  without  a  diph- 
thera  is  indeed  asserted.  The  reasons  for  regarding  its  oc- 
currence as  improbable  have  been  elsewhere  given.  The 
distinctive  characteristics  of  diphtheritic  false  membrane 
have  elsewhere  been  stated.  This  membrane  in  the  fauces 
and  pharynx  is  never  altogether  superficial  to  the  mucous 
membrane.  Though  the  depth  to  which  it  involves  the  epithe- 
lial layers  varies  greatly  in  different  cases,  yet  even  in  its 
most  superficial  form  it  is  so  intimately  connected  with  the 
subjacent  tissues  that  if  it  be  scraped  or  torn  away,  a  raw 
and  bleeding  surface  is  exposed. 

In  non-diphtheritic  pharyngitis  we  often  see  whitish  patches 
of  pultaceous  follicular  secretion  or  smearings  of  glairy  tena- 
cious mucus,  or  ulcers  of  various  kinds  covered  over  with,  or 
surrounded  to  some  little  distance  by,  yellowish  or  grayish 
muco-pus,  or,  in  some  cases,  with  a  superficial  and  fragile 
membranous  formation  which  is  undoubtedly  a  true  fibrinous 
or  croupous  exudation.  These  forms  of  ulcerative  pharyn- 
gitis have  been  variously  designated  as  "ulcero-membranous 
angina"  by  Da  Costa,1  "common  membranous  sore-throat" 
and  "herpetic  sore-throat,"  by  J.  Solis-Cohen,2  "confluent 
herpes  of  the  throat"  by  Morell  Mackenzie,3  and  "drain- 
throat,"  a  form  of  septic  sore-throat  attended  with  ulceration, 
by  S.  Solis-Cohen.4 

The  appearances  presented  by  these  affections  may  at  the 

1,1  Medical  Diagnosis,"  Phila.,  1881,  p.  431. 

2"  Diseases  of  the  Throat,"  New  York,  1879,  p.  103. 

3  Op.  cit.,  p.  52. 

4  "The  Diphtheroid  Throats,"  Archives  of  Paediatrics,  February, 
1888,  p.  92. 


124  DIPHTHERIA;    ITS    NATURE    AND   TREATMENT. 

first  view  be  very  deceptive  to  the  inexperienced  eye ;  but  their 
true  character  may  be  readily  ascertained  by  brushing  them 
with  a  swab,  or,  still  better,  throwing-  a  stream  of  water  upon 
them  from  a  syringe.  In  aphthous  or  herpetic  angina  the 
little  vesicles  and  the  resulting-  ulcers  are  readily  recognized 
when  clearly  exposed  to  view  by  this  method,  and  the  fibri- 
nous pellicles  just  referred  to  have  entirely  vanished  from  the 
scene,  or  just  enough  fragments  of  them  remain  to  make 
clearly  evident  their  fragile,  superficial  and  non-  diphtheritic 
character. 

But  by  far  the  most  frequent  occasion  of  error  in  diagnosis 
is  the  very  common  affection  known  as  acute  follicular  or 
lacunal  tonsillitis.  The  tonsils  are  irregularly  ovoid  bodies, 
the  surface  of  which  is  penetrated  by  a  varying  number  of 
slit-like  or  circular  orifices  of  a  system  of  internal  cavities, 
crypts  or  lacunee,  from  which  numerous  follicles  branch  out 
into  the  substance  of  the  gland.  "  The  crypts  of  largest  size 
and  greatest  depth  are  as  a  rule  found  in  the  middle  part  of 
the  tonsil.  (See  figure  9.)  The  crypts  are  generally  filled 
more  or  less  with  a  yellowish  substance  composed  of  fab 
molecules,  loosened  pavement  epithelium,  lymph  corpuscles, 
small  molecular  granules  and  cholesterin  crystals,  which  prob- 
ably proceed  from  retained  and  decomposed  epithelial  matter, 
and  perhaps  now  and  then  from  the  bursting  of  follicles  whose 
cells  have  increased  by  proliferation  and  have  undergone  a 
retrograde  metamorphosis  and  fatty  degeneration/' 1 

Acute  follicular  tonsillitis  occurs  sporadically  in  connection 
with  ordinary  catarrhal  pharyngitis,  endemically  from  vari- 
ous local  insanisary  conditions,  and  epidemically.  In  this  last 
form  it  is  undoubtedly  a  specific  disease,  and  is  probably  in 
some  degree  contagious.  I  have  been  led  to  this  last  conclu- 
sion from  having  so  often  seen  it  go  through  families  of  chil- 

1  From  "  The  Tonsils,  their  General,  Surgical  and  Minute  Anatomy," 
by  D.   Bryson  Delavan,  M.D.,  Archives  of   Laryngology,  December, 

1880. 


DIAGNOSIS. 


125 


dren,  successive  cases  occurring-  at  intervals  of  one,  two  or 
three  days,  just  as  occurs  with  dipntheria  or  scarlatina. 

Follicular  tonsillitis  is  not  a  milder  grade  of  diphtheria, 
but  is  a  totally  distinct  disease.  Diphtheria,  it  is  true,  may 
supervene  upon  follicular  tonsillitis,  as  upon  other  catarrhal 


Fig.  9.— Hypertrophied  Tonsil.    (Enlarged  drawing,  Luschka.)    This  figure  shows  the  posi- 
tion of  the  lacunae  and  their  orifices  ia  the  tonsil,  as  is  above  described. 


affections,  but  then  it  is  usually,  at  least,  only  after  the  latter 
has  run  its  course.  As  this  requires  only  a  few  days,  it  is  not 
strange  that  the  two  affections  have  been  supposed  by  some 
to  be  related. 

Follicular  tonsillitis  differs  from  diphtheria  in  not  causing 
constitutional  poisoning',  either  septic  or  specific.     It  is  not 


126  DIPHTHERIA;     ITS   NATURE   AND   TREATMENT. 

accompanied  with  nephritis  (except  as  any  febrile  catarrhal 
affection  may  occasionally  be);  it  is  not  followed  by  paralysis, 
and  I  have  never  known  of  a  fatal  case.1 

The  onset  of  follicular  tonsillitis  is  undistinguishable  from 
that  of  diphtheria  in  the  amount  of  febrile  and -nervous  dis- 
turbance which  accompanies  it.  Its  second  stage,  that  of  fol- 
licular exudation  on  the  inflamed  tonsil,  may  closely  resemble 
diphtheria.  Its  third  stage,  which  occurs  after  two  or  three 
days,  is  that  of  the  disappearance  of  this  exudation,  exposing 
in  its  place  peculiar  appearances  of  erosion  or  excavation  in 
the  surface  of  the  tonsil. 

In  the  second  stage,  or  that  of  exudation,  we  may  often  see 
whitish  or  yellowish  points  projecting,  or  liquid  oozing  from 
one  or  more  of  the  lacunal  orifices  of  the  tonsils.  The  diag- 
nosis is  then  easily  made,  for  these  appearances  are  pathog- 
nomonic of  follicular  tonsillitis.  It  is  made  easy  in  other 
cases  by  the  evidently  soft  and  pultaceous  character  of  the 
deposit  on  the  tonsil,  and  by  its  lying  loosely  and  superficially 
on  its  surface,  from  which  it  is  easily  removed  by  rubbing  it 
with  a  swab. 

There  is  a  smaller  proportion  of  cases,  but  yet  very  numer- 
ous in  the  aggregate,  in  which  the  diagnosis  is  much  more 

1  In  the  Section  on  Practice  of  the  New  York  Academy  of  Medicine, 
Dr.  J.  Lewis  Smith  (see  New  York  Medical  Record,  Nov.  27th,  188G) 
stated  as  the  result  of  his  large  observation  of  the  two  diseases  his  belief 
that  they  are  not  related,  except  that  diphtheria  may  occur  as  a 
secondary  disease.  Dr.  L.  Emmet  Holt,  from  the  observation  of  three 
hundred  recorded  cases  of  tonsillitis,  concurred  in  this  view.  Dr.  Holt 
also  quoted  Dr.  Haig-Brown,  medical  officer  to  the  Charterhouse 
school  in  England,  who  had  in  three  years  met  with  four  hundred  and 
sixteen  cases  of  tonsillitis  among  the  five-hundred  boys  who  were  under 
his  supervision,  but  only  one  case  of  genuine  diphtheria,  and  who  had 
recorded  two  epidemics  of  simple  tonsillitis  in  which  the  disease  was 
unquestionably  spread  by  contagion,  and  Dr.  Gr.  A.  Spalding  of  this 
city,  who  had  stated  that  at  the  House  of  Refuge  cases  of  tonsillitis 
were  constantly  occurring,  yet  no  clear  case  of  diphtheria  had  been 
seen  there  in  years,  and  Dr.  Gribney  of  this  city,  who  had  made  a  similar 
statement  in  reference  to  the  Hospital  for  the  Ruptured  and  Crippled 
during  his  term  of  service  there. 


DIAGNOSIS.  127 

difficult.  These  cases  are  thus  described  by  Dr.  Geo.  M.  Lef- 
ferts : l  "  Have  you  not  often  seen  in  these  cases  of  follicular 
tonsillitis  an  aggregation  of  the  grayish-white  pultaceous 
masses  which  block  up  the  mouths  of  the  diseased  and  oc- 
cluded crypts  to  such  an  extent  that  not  only  is  an  apparent, 
but  a  real  pseudo-membrane  formed — one  thickened  by  the 
products  of  cellular  growth  and  decay  (fungi  and  bacteria) 
and  rendered  coherent  by  the  inflammatory  hyperplasia  ?  A 
membrane  which  may  occupy  only  part  of  the  tonsillar  sur- 
face appears  here  and  there  in  patches,  or,  more  rarely,  still 
not  infrequently,  covers  it  entirely.  The  appearance  is  not  an 
unusual  one,  and  the  attendant  constitutional  disturbance 
well-known." 

Dr.  Lefferts  in  this  connection  refers  also  to  the  infectious 
catarrhal  tonsillitis  which  has  been  described  by  Fox  and 
other  English  writers,  under  the  name  of  "  spreading  quinsy," 
which  is  essentially  an  inflammation  of  the  tonsils,  extending 
more  or  less  into  the  pharynx,  and,  sometimes,  to  the  neigh- 
boring submaxillary  and  cervical  glands.  It  is  essentially  a 
filth-disease,  is  communicable,  is  attended  with  a  certain 
amount  of  anaemia  and  depression,  the  mortality  from  it  is 
slightly  greater  than  from  ordinary  tonsillitis,  and  it  is  never 
followed  by  paralysis.  According  to  Fox's  observations  it  is 
never  accompanied  with  a  well-marked  membrane.  In  this 
respect  my  own  observations  have  differed  from  those  of  Dr. 
Fox,  as  I  have  seen  more  than  one  epidemic  of  an  affection 
answering  in  all  other  respects  to  the  description  just  given, 
in  which  the  occurrence  of  quite  a  firm  membranous  forma- 
tion on  the  tonsil  was  not  uncommon. 

While  the  patches  in  follicular  tonsillitis  are  more  usually 
composed  of  the  conglomerate  follicular  exudation  above  re- 
ferred to,  spread  out  and  inspissated,  they  are  not  infrequently 
either  wholly  or  in  part  a  true  fibrinous  or  "croupous"  mem- 

1 "  Some  of  the  Commoner  Affections  of  the  Tonsils,"  New  York 
Medical  Record,  1879,  16,  p.  601. 


128  diphtheria;   its  nature  and  treatment. 

brane.  These  two  elements  are  often  intermingled.  The 
fibrinous  form  has  been  regarded  and  described  by  some  as  a 
separate  affection  from  follicular  tonsillitis,  under  the  name  of 
croupous  tonsillitis.  Though  some  cases  apparently  justify 
this  discrimination,  yet  my  observation,  which  has  included  a 
great  number  of  cases,  has  led  me  to  regard  them  as  being, 
usually,  at  least,  simply  different  forms  of  the  same  affection. 
The  other  view  is  taken  by  Dr.  L.  Emmet  Holt  in  a  very  val- 
uable paper  on  the  subject; 1  but  the  following  passage  in  Dr. 
Holt's  paper  would  seem  to  favor  my  own  conclusion.  Having 
referred  to  other  designations  given  to  this  affection  ("  spread- 
ing quinsy/'  "  catarrhal  diphtheria,"  etc.),  Dr.  Holt  continues, 
"  I  prefer,  with  Carmichael,2  to  regard  them  as  cases  of  croup- 
ous tonsillitis.  This  writer  describes  the  pathological  appear- 
ances in  the  following  words :  'The  gland  is  a  pale  red;  the 
patch  of  a  yellowish-white  color,  confined  to  the  tonsil,  easily 
separated,  leaving  a  loss  of  epithelium,  but  the  gland  otherwise 
intact.  Microscopically,  besides  the  cell-elements  of  follicular 
tonsillitis,  blood-corpuscles  in  a  fibrinous  matrix  are  present.' " 
The  italics  are  mine.  Yet  my  own  observations  accord  with 
those  of  Dr.  Holt  that  in  some  cases  the  fibrinous  or  "  croup- 
ous" element  in  the  affection  is  the  only  noticeable  feature. 
Our  observations  agree  upon  the  important  points  that  it  is 
limited  to  the  tonsil,  that  it  closely  resembles  diphtheria,  for 
which  it  is  doubtless  very  often  mistaken,  and  that  it  is  not 
diphtheria.  Indeed  the  only  explanation  of  the  fact  that  the 
descriptions  of  this  very  common  affection  in  medical  litera- 
ture are  so  few  and,  with  a  few  exceptions,  so  incomplete,  is 
that  it  has  been  regarded  by  a  large  proportion  of  observers 
as  a  form  of  diphtheria.     The  error  is  a  very  natural  one. 

The  following  case  is  described  by  Dr.  Holt  and  stated  to 
be  one  of  nineteen  in  all  essential  respects   similar  to  it  of 


1 "  The  Non-identity  of  Croupous  Tonsillitis  with  Diphtheria."  Trans- 
actions of  the  Medical  Society  of  the  State  of  New  York,  1886,  p.  552. 
2  Edinburgh  Medical  Journal,  July,  1884. 


DIAGNOSIS.  129 

which  he  has  notes:  "On  November  11,1  saw  a  stout  well- 
nourished  girl  of  ten  years,  who  was  reported  to  have  been 
perfectly  well  until  the  morning"  of  that  day.  She  was  taken 
at  eleven  o  clock  with  a  chill,  vomited  twice,  complained  of 
pains  in  the  chest  and  seemed  quite  sick.  The  temperature, 
when  seen  three  hours  later,  was  103.2°  F.,  pulse  140,  respira- 
tion 32.  Examination  of  the  chest  revealed  nothing  abnormal, 
but  on  inspecting  the  throat  the  tonsils  were  found  much 
swollen,  and  the  right  completely  covered  by  a  thick  yellowish 
gray  membrane,  the  left  being  about  two-thirds  covered.  On 
the  following  day  the  temperature  was  102.1°,  the  membrane 
was  still  distinctly  circumscribed,  showing  no  tendency  to 
spread,  but  was  more  yellow  in  color.  On  the  third  day  the 
temperature  was  101.6°,  and  after  that  it  was  normal.  On 
the  fourth  day  the  throat  was  practically  well." 

This  case  is  a  graphic  illustration  of  what  I  have  seen 
in  numerous  instances,  and  have  referred  to  in  previous 
publications,  the  first  having  been  in  1880.  In  that  paper 
I  referred  to  cases  which  I  had  observed  of  even  a  more 
deceptive  character  than  the  one  just  described,  as  follows: 
"  In  occasional  instances  nearly  the  whole  surface  of  the  tonsil 
is  covered  with  a  thick  and  firm  investment  of  this  character. 
If  this  appearance  is  accompanied,  as  it  sometimes  is,  with 
grave  constitutional  disturbance,  distress  and  prostration ;  if 
there  is  some  enlargement  of  cervical  glands;  if  the  throat  is 
filled  with  tenacious  muco-pus,  perhaps  rendered  sanious  by 
points  of  ulceration;  if  there  is  foetor  of  the  breath;  if  on  the 
uvula  or  the  faucial  pillars  are  the  whitish  smearings  above 
referred  to,  the  physician  who  has  not  studied  this  subject 
carefully  and  well  naturally  supposes  that  he  has  to  do  not 
only  with  a  case  of  diphtheria,  but  a  grave  one,  and  is  de- 
lighted at  his  success  in  curing  it  in  two  or  three  days,  as  he 
is  certain  to  do." 

But  it  may  be  asked,  what  ground  of  certainty  is  there  that 

such  a  case  is  not  in  reality  diphtheritic  ?     I  answer,  this — 
9 


130  diphtheria;  its  nature  and  treatment. 

that  having  recognized  its  true  character  by  the  methods  now 
to  be  stated,  we  can  accurately  predict  the  subsequent  course 
of  events,  which  is  that  it  will  not  extend  beyond  the  tonsils, 
and  that  after  two  or  three  days  the  diphtheroid  deposits  will 
have  vanished,  leaving-  in  their  place  the  typical  appearances 
of  erosion  or  excavation  in  the  tonsil,  and  that  there  will  be 
none  of  the  distinctive  constitutional  symptoms,  nor  the 
sequelae  of  diphtheria. 

How  shall  the  differential  diagnosis  be  made  ?  Not  by  the 
circumstance  that  the  exudation  is  limited  to  the  tonsil  or 
tonsils,  for  that  is  often  true  in  diphtheria ;  nor  by  its  short 
duration,  for  that  is  equaled  by  very  mild  forms  of  diphtheria; 
nor  by  the  severity  or  mildness  of  the  accompanying  febrile 
disturbance,  for  that  varies  greatly  in  both  affections ;  nor  by 
the  test  of  infection  or  non-infection,  for  catarrhal  tonsillitis 
is  sometimes  infectious;  nor  even  by  the  presence  or  absence  of 
albuminuria,  for  reasons  which  have  been  elsewhere  stated. 

"We  are  told  by  various  writers  that  the  diagnosis  of  follic- 
ular tonsillitis  may  be  made  by  scraping  the  membraniform 
investment  from  the  tonsil,  or  forcing  out  the  cheesy  contents 
of  the  crypts  by  pressure,  or  thrusting  a  probe  into  the  dis- 
tended lacunal  orifices,  which  methods  in  the  case  of  a  suffer- 
ing and  struggling  child  are  unnecessarily  heroic. 

In  the  paper  from  which  I  have  just  quoted  I  called  atten- 
tion to  two  points  or  methods  in  this  diagnosis,  of  which 
experience  had  taught  me  the  valuable  practical  utility,  and 
the  added  experience  of  subsequent  years  has  only  tended  to 
confirm  my  estimate  of  that  utilitj''. 

The  first  of  these  points  is  the  location  of  the  membrani- 
form patches  in  follicular  tonsillitis.  These  patches  being 
usually  formed  wholly  or  in  part  by  exudation  from  the  lacu- 
nal openings,  or  being  at  least  the  result  of  an  inflammation 
which  involves  the  follicular  portion  of  the  tonsil,  are  in  rela- 
tion to  those  openings,  and  are  consequently  located  on  the 
more  central  portion  of  the  convexity  of  the  tonsil  which  is 


DIAGNOSIS.  131 

the  site  of  the  principal  and  most  numerous  openings.     (See 
figure  1,  page  134). 

On  the  other  hand,  a  patch  of  true  diphtheritic  membrane 
when  it  is  limited  to  the  tonsil  is  not  usually  seen  on  that  por- 
tion of  its  surface  only,  but  occupies  a  more  lateral  or  marginal 
position,  the  true  diagnostic  point  being  the  relation  or  want 
of  relation  to  the  lacunas  of  the  tonsil.  Hence,  if  on  the  first 
inspection  of  the  throat  a  membranous  patch  is  seen  covering 
the  central  portion  of  the  convexity  of  one  or  both  tonsils,  and 
is  limited  to  the  tonsil,  it  may  be  regarded  as  very  probable 
that  the  affection  is  follicular  tonsillitis  rather  than  diphthe- 
ria ;  while  a  membranous  patch,  however  small  and  slight  in 
appearance,  which  is  seen  on  the  marginal  portion  of  the  ton- 
sillar surface,  and  is  evidently  not  in  relation  to  the  lacunal 
orifices  as  its  source,  should  be  carefully  investigated. 

I  have  seen  true  diphtheritic  membrane  in  its  formative 
stage  extending  in  slight  streaks  or  spots  across  the  tonsil. 
In  those  instances  it  has  been  easily  to  be  seen  that  the 
streaks  or  spots  did  not  emerge  from  the  lacunal  openings, 
and  bore  no  relation  to  them,  which  is,  in  reality,  the  essen- 
tial point  to  be  ascertained. 

The  second  method  is  syringing  the  throat  with  warm  salt- 
water. In  follicular  tonsillitis  this  will  cleanse  the  throat  of 
much  deceptive  material.  The  membraniform  covering  of  the 
tonsils  will  be  in  part  at  least  broken  up  and  washed  away, 
showing  its  friable  and  superficial  character,  and  its  relation 
to  the  distended  lacunal  orifices.  A  prompt  and  accurate 
diagnosis  is  thus  made  practicable  by  a  simple  and  readily 
available  method  in  many  cases  in  which  it  would  otherwise 
be  difficult  or  impossible. 

Like  most  other  "  ready  methods  "  in  diagnosis,  those  which 
I  have  now  mentioned  require  to  be  used  with  due  reserve  and 
discretion,  especially  by  inexperienced  physicians  and  at  times 
when  diphtheria  is  epidemic.  It  cannot  be  denied  that  there 
are  cases  in  which  the  most  competent  and  experienced  phy- 


132  diphtheria;  its  nature  and  treatment. 

sician  must  reserve  his  positive  diagnosis  for  a  day  or  two, 
and  rare  instances  in  which  some  doubt  must  remain  even 
after  the  most  careful  consideration  of  all  the  attendant  cir- 
cumstances. Yet  the  number  of  cases  in  which  these  tests 
when  applied  until  accurate  observation  will  fail  is  surpris- 
ingly small.  This,  I  am  sure,  would  he  testified  to  by  any  one 
of  at  least  twenty  physicians  who,  during  the  past  fifteen 
years  as  my  assistants  in  the  out-door  visiting  at  Demilt  Dis- 
pensary, have  had  frequent  occasion  to  apply  them,  and  some 
of  whom  are  now  well  known  in  the  profession.  I  have  by 
the  application  of  these  methods  in  numerous  cases,  both  in 
dispensary  and  private  practice,  been  enabled  to  dispel  the 
alarm  occasioned  by  very  formidable  "diphtheritic''  appear- 
ances by  assuring  the  sufferers  or  their  friends  of  their  proba- 
bly innocent  and  transient  character,  and  have  been  justified 
by  the  event.  I  have  also  been  called  in  consultation  in  quite 
a  number  of  cases  of  supposed  diphtheria  of  some  severity  and 
danger,  in  which  I  have  from  the  same  considerations  been 
enabled  to  assure  the  attending  physicians  that  their  patients 
would  in  all  probability  make  a  rapid  and  complete  recovery, 
frankly  stating  to  them  the  diagnostic  grounds  of  my  belief, 
and  the  prediction  has  in  every  instance  been  verified. 

I  have  under  other  circumstances  personally  known  of  not 
a  few  instances  in  which  follicular  tonsillitis  has  been  mistaken 
for  diphtheria  by  intelligent,  conscientious  and  not  iu  experi- 
enced physicians.  While  this  error  is  greatly  to  be  depre- 
cated, not  only  on  account  of  the  needless  alarm  and  incon- 
venience which  it  is  liable  to  occasion,  but  still  more  because, 
as  has  unfortunately  been  but  too  widely  illustrated  in  the 
literature  of  diphtheria,  it  renders  in  proportion  to  its  fre- 
quency the  teachings  of  therapeutical  experience  worthless  or 
misleading,  the  opposite  error  of  the  mistaking  of  diphtheria 
in  its  mildest  forms  or  its  slight  beginnings,  for  its  benign 
counterfeit,  may,  in  its  immediate  results  at  least,  be  even 
more  disastrous. 


DIAGNOSIS.  133 

It  hardly  needs  to  be  remarked  that  while  the  diagnosis  is 
in  any  degree  doubtful,  the  patient  should  be  isolated,  and  the 
case  treated  as  one  of  tonsillar  diphtheria. 

The  following  case  illustrates  certain  other  elements  of  in- 
terest, which  may  sometimes  attend  this  differential  diagno- 
sis: In  1881  I  saw,  in  consultation  with  two  well-known  physi- 
cians,  the  little  daughter  of  another  well-known  physician  of 
this  city.  She  was  suffering  with  a  violent  inflammation  of 
the  throat,  accompanied  with  exudation  upon  the  tonsils. 
There  was  also  laryngeal  stenosis,  so  grave  that  the  necessity 
of  tracheotomy  was  imminent.  The  question  under  anxious 
consideration  was,  Is  the  tonsillar  disease  follicular  or  diph- 
theritic ?  After  a  careful  examination,  and  with  some  hesita- 
tion on  account  of  the  gravity  of  the  case,  I  concurred  with 
one  of  the  other  consultants  in  the  view  that  it  was  follicular, 
and  on  that  diagnosis  we  based  a  favorable  prognosis  for  the 
impending  tracheotomy,  believing  that  the  laryngeal  affection 
would  prove  to  be  catarrhal.  The  operation  presently  became 
necessary.  It  had  a  successful  result,  there  being  no  evidence 
of  the  presence  of  false  membrane  in  the  larynx  or  trachea. 
At  the  same  time  the  little  sister  of  the  patient  was  violently 
attacked  as  she  had  been,  except  that  there  was  no  laryngitis. 
The  latter  case  proved  unusually  grave  and  persistent,  with 
serious  constitutional  disturbance  and  depression,  but  yet 
progressed  and  terminated  as  follicular  tonsillitis.  It  should 
be  added  that  in  the  residence  of  these  patients — a  "first- 
class  "  one  on  Madison  Avenue — there  were  found  to  be  serious 
defects  in  the  plumbing.  This  case  is  illustrative  of  the  im- 
portance of  an  accurate  diagnosis  in  cases  requiring  tracheo- 
tomy in  order  to  give  real  value  to  statistics  of  the  results  of 
that  operation  in  diphtheritic  and  non-diphtheritic  cases. 


134  diphtheria;  its  nature  and  treatment. 


Explanation  of  the  Following  Plate. 

Figure  1  shows  a  usual  and  easily  recognizable  form  of  follicular 
tonsillitis  in  a  woman  thirty  years  of  age  on  the  third  day  of  her  illness. 
The  characteristic  location  of  the  exudation  and  its  evident  relation  to 
the  lacunal  orifices  are  here  illustrated. 

Figure  2  depicts  tonsillar  diphtheria  in  a  girl  ten  years  of  age  on 
the  third  day  of  her  illness.  She  was  one  of  seven  members  of  one 
family  in  the  Willard  Parker  Hospital  for  Contagious  Diseases  who 
had  been  attacked  nearly  simultaneously,  including  the  mother  and 
five  other  children.  In  the  mother  and  the  four  elder  children  the 
affection  was  limited  to  the  tonsils  and  was  mild  in  character.  A  child 
about  three  years  of  age  had  diphtheria  of  the  tonsils,  soft  palate  and 
nares,  from  -which  she  recovered.  The  youngest — an  infant — was  in- 
tubated for  laryngeal  diphtheria,  and  died  on  the  following  day  with 
the  symptoms  of  the  extension  of  the  membranous  affection  into  the 
bronchial  tubes. 

Figure  3  represents  diphtheria  of  the  soft  palate  and  tonsils  in  a 
female  patient  twenty-six  years  of  age,  on  the  sixth  day  of  the  disease. 
The  uvula,  which  in  this  case  is  small  and  unaffected,  is  nearly  con- 
cealed from  view  by  the  swelling  of  the  adjacent  parts. 

Figure  4  (from  Dr.  Lenox  Brown's  work  on  Diseases  of  the  Throat) 
is  a  rhinoscopic  view  of  the  posterior  nares  in  a  fatal  case  of  naso-pha- 
rnygeal  diphtheria. 


Fiqure  2. 


Figure  -4. 


Figure 


Figure  3 


Lindner,  Eddy  &  Ci.*.tjss,  Lith.  N    Y- 


DIAGNOSIS.  135 

Scarlatina  is  another  affection  with  which  diphtheria  is 
very  liable  to  be  confounded.  This  liability  occurs  usually  in 
those  cases  of  scarlatina  in  which  the  distinctive  features  of 
the  disease,  especially  the  eruption,  are  either  absent  or  are  so 
slight  and  ill-defined  as  to  be  overlooked,  and  in  which  pseudo- 
membranous exudation  is  present. 

The  distinctive  features  indicative  of  scarlatina  are  in  the 
earlier  stage  the  following:  the  fever  is  usually  higher  in  scar- 
latina, especially  in  the  malignant  form  without  eruption; 
vomiting,  common  to  both,  is  especially  characteristic  of  the 
first  onset  of  scarlatina.  The  well-known  appearances  of  the 
tongue  in  scarlatina  are  usually  more  or  less  typical.  The 
appearance  of  the  throat  formerly  described  by  me J  as  char- 
acteristic of  scarlatina, — namely,  a  bright  diffused  or  punctate 
redness  extending  from  one  or  both  tonsils  along  the  faucial 
half-arches  to  the  uvula,  and  shading  off  more  or  less  gradu- 
ally on  the  soft-palate,  is  rarely  altogether  wanting.  The 
diphtheroid  form  of  scarlatinal  angina,  which  is  also  charac- 
teristic, is  described  in  the  chapter  on  secondary  diphtheria,  to 
which  the  reader  is  referred. 

At  a  later  period  the  well-known  tendency  of  scarlatinal 
inflammation  to  extend  into  the  nares  and  into  the  middle  ear 
is  a  very  suggestive  diagnostic  feature,  the  latter  region  being 
very  rarely  invaded  by  primary  diphtheria. 

Albuminuria  and  nephritis  are  the  more  probably  of  a 
scarlatinal  origin  in  proportion  to  the  lateness  of  their  occur- 
rence, and  also  to  their  presenting  certain  features;  as  the 
presence  of  blood  in  the  urine,  which  is  frequent  in  scarlatinal 
and  infrequent  in  diphtheritic  albuminuria,  and  their  being  ac- 
companied b}^  subcutaneous  oedema,  of  which  the  same  is  true. 

The  evidences  of  the  invasion  of  the  nasal  passages  by 
diphtheria  have  been  described  in  the  chapter  on  symptoms. 

1 "  Clinical  Observations  on  the  Early  Stages  of  Scarlatina."  Read 
before  the  New  York  Academy  of  Medicine.  N.  Y.  Medical  Record, 
March  23rd  and  30th,  1878. 


136  diphtheria;  its  nature  and  treatment. 

When  this  occurrence  is  thus  made  probable,  but  false  mem- 
brane is  not  visible  on  ordinary  inspection,  the  diagnosis  may 
in  some  cases  be  readily  completed  by  the  use  of  the  nasal 
speculum  or  the  rhinoscopic  mirror;  but  a  universally  availa- 
ble method  is  the  syringing-  of  the  nares,  as  will  be  described 
in  the  chapter  on  treatment.  This  procedure  will  first  demon- 
strate the  occlusion  of  the  nasal  passages,  and,  if  persevered 
in,  will  usually  dislodge  and  bring  away  shreds  or  larger  por- 
tions, of  membrane. 

When  the  symptoms  of  croup  are  preceded  or  accompanied 
by  the  presence  of  false  membrane  in  the  pharynx  or  nares, 
the  laryngeal  affection  is,  as  a  rule,  pseudo-membranous.  In 
cases  in  which  they  are  not  thus  accompanied  it  is  sometimes 
difficult  to  decide  whether  it  is  membranous  or  catarrhal. 
Positive  evidence  that  it  is  the  former  may  in  some  cases  be 
obtained  by  the  aid  of  the  laryngoscope,  and  in  some  others  is 
afforded  by  the  coughing  up  by  the  patient  of  shreds  of  mem- 
brane. When  an  attack  of  croup  follows  exposure  to  the  con- 
tagion of  diphtheria,  or  occurs  during  an  epidemic  of  that  dis- 
ease, it  may  be  presumed  to  be  membranous.  Some  children 
are  by  individual  or  family  predisposition  subject  to  attacks  of 
catarrhal  croup  after  taking  cold.  In  such  patients  the  recur- 
rence of  that  affection  is  under  ordinary  circumstances  more 
probable  than  the  occurrence  of  membranous  croup,  though 
the  latter  is  of  course  not  impossible.  A  sudden  onset,  especi- 
ally at  night,  is  characteristic  of  spasmodic  croup,  and  if  it 
have  not  been  preceded  by  symptoms  of  laryngitis  warrants 
that  diagnosis.  Mere  remissions  in  the  symptoms,  however, 
with  sudden  exacerbations,  are  by  no  means  so  conclusive,  since 
a  spasmodic  element  is  sometimes  very  pronounced  in  the 
earlier  stages  both  of  catarrhal  and  membranous  croup.  The 
persistency  and  steady  increase  of  serious  croupal  symptoms 
may  be  due  either  to  membranous  laryngitis  or  to  severe 
catarrhal  laryngitis.  The  former  is  the  more  usual  cause  in 
such  grave  cases,  and  is  therefore  the  more  probable  one  in 


DIAGNOSIS.  137 

any  given  case;  yet  in  the  absence  of  positive  evidence  of  the 
existence  of  membrane  the  diagnosis  can  never  be  absolute, 
since  some  such  cases  have  been  found  after  tracheotomy  or 
at  the  autopsy  to  be  purely  catarrhal. 

Reasons  have  elsewhere  been  given  for  the  belief  that  there 
is  a  membranous  croup  which  is  not  diphtheria,  but  yet  that 
under  ordinary  circumstances  the  two  affections  are  so  liable 
to  be  complicated  or  confounded  that  the  diagnosis  of  the 
former  can  rarely  be  a  positive  one.  This  diagnosis  must  re- 
late mainly  to  the  following  points: — Simple  membranous 
croup  is  not  traceable  to  the  contagion  or  the  endemic  or  epi- 
demic influence  of  diphtheria,  but  to  non-specific  causes  which 
are  usually  meteorological;  it  occurs  by  marked  preference  in 
the  colder  seasons  of  the  year  and  in  exposed  situations;  it  is 
itself  non-contagious;  it  is  sporadic,  or,  if  it  occurs  epidemic - 
alh*,  does  so  as  the  evident  result  of  special  meteorological 
conditions;  it  is  entirely  or  mainly  limited  to  the  air-passages; 
it  is  an  acute  local  inflammation  attended  with  fever  which 
never  becomes  adynamic;  it  is  never  attended  with  the  symp- 
toms of  diphtheritic  or  septic  constitutional  poisoning;  it  is 
fatal  only  by  mechanical  obstruction  to  respiration;  it  is  never 
followed  by  paralysis. 

The  presence  of  croupous  bronchitis  may  be  regarded  as 
probable  when,  in  the  course  of  laryngotracheal  diphtheria, 
there  is  a  marked  increase  in  temperature  and  in  frecpiency 
of  respiration,  with  the  physical  signs  of  bronchitis  and 
broncho-pneumonia;  but  the  diagnosis  can  never  be  positive 
except  from  the  evidence  afforded  by  the  coughing  up  of  mem- 
branous casts  of  the  bronchial  tubes. 

The  unreliability  of  S3Tmptoms  which  point  to  the  existence 
of  oesophageal  diphtheria  has  been  referred  to  in  the  chapter 
on  symptoms.  Evidence  afforded  by  the  laryngoscope,  or  by 
the  expectoration  of  membrane  from  that  location,  is  the  only 
basis  of  a  positive  diagnosis.  Gastric  or  intestinal  diphtheria 
can  be  positively  recognized  during  life  only  from  the  vomit- 
ing or  the  voiding  of  its  pseudo-membranous  products. 


138  DIPHTHERIA;    ITS   NATURE    AND    TREATMENT. 

When  a  paralysis  with  the  characteristics  which  have  heen 
elsewhere  described  follows  a  recognized  attack  of  diphtheria, 
there  can  be  no  question  as  to  the  diagnosis.  In  those  cases 
in  which  the  preceding  disease  has  been  unrecognized,  the 
nature  of  the  paralysis  is  usually  made  plain  by  the  fact  that 
it  affects  the  palate  only  or  mainly,  or  that  having  first  at- 
tacked that  organ  it  has  successively  invaded  other  parts  in 
an  order  and  in  a  manner  which,  though  subject  to  variations, 
are  yet  typical  of  diphtheritic  paralysis.  A  history  of  a  pre- 
ceding sore  throat  or  coryza  can  then  usually  be  obtained.     In 

* 

rare  cases  the  palate  may  not  have  been  affected,  and  the 
pararysis  when  it  presents  itself  to  the  physician  may  have 
become  more  or  less  general,  a  considerable  time  having 
elapsed  since  the  attack  of  diphtheria.  Even  in  such  a  case 
there  are  usually  evident  characteristics  of  diphtheritic  paral- 
ysis in  the  history  of  its  gradual  progress  from  one  part  to 
another,  one  having  wholly  or  partly  recovered  its  strength 
as  others  have  become  weak,  in  the  disturbances  of  vision  and 
the  strabismus,  and  even  in  the  fact  that  when  the  palate  is 
not  at  first  affected,  it  is  often  attacked  at  a  later  period. 
Even  when  it  most  deviates  from  the  usual  order  of  occur- 
rences there  is  in  its  very  capriciousness  and  irregularity,  in 
its  incompleteness,  in  the  intermingling  of  sensory  disturbances 
with  motor  paresis,  a  physiognomy  which  is  recognizable  from 
that  of  most  other  paralyses.  Diphtheritic  paralysis  of  the 
extremities  may  simulate  locomotor  ataxia  in  the  incoordina- 
tion of  movements  and  the  loss  of  the  knee-jerk,  but  it  may 
usually  be  distinguished  from  that  affection  by  its  more  rapid 
onset,  by  the  greater  muscular  weakness  and  by  the  absence 
of  the  characteristic  pains.  It  differs  from  simple  paraplegia 
in  its  history,  in  the  loss  of  the  knee  jerk  and  in  its  compara- 
tively short  duration.  In  acute  atrophic  paralysis  the  change 
in  electro-muscular  contractility  is  usually  much  greater,  and 
there  is  no  disturbance  of  sensation.  In  hysterical  paralysis 
the  palate  is  never  affected. 


CHAPTER  IX. 

PROGNOSIS. 

Diphtheria  has  always  been  justly  regarded  as  a  most 
dangerous  disease.  In  many  recorded  epidemics  a  large  ma- 
jority of  all  cases  have  proved  fatal.  Even  at  the  present 
time,  and  in  spite  of  all  our  therapeutic  progress,  its  general 
fatality  continues  to  be  very  great. 

The  proportion  of  deaths  from  diphtheria  to  reported  cases 
of  the  disease  in  this  city  during  the  eight  years,  1880  to  1887, 
inclusive,  according  to  the  returns  of  the  Board  of  Health,  is 
shown  in  the  following  figures,  for  which  I  am  indebted  to  the 
courtesy  of  Dr.  John  T.  Eagle : 


Year. 

No.  of  Cases. 

No.  of  Deaths. 

.rercenta 
of  Death 

1880 

3307 

1390 

•  42.03 

1881 

5272 

2249 

42.65 

1882 

3507 

1525 

43.48 

1883 

2906 

1009 

34.37 

1884 

2201 

1090 

49.47 

1885 

2920 

1325 

45.37 

1886 

3737 

1727 

46.21 

1887 

5923 

2167 

36.58 

A 

.  42.62 

The  statistics  of  the  disease  in  Boston  during  the  same 
period,  which  have  been  kindly  given  me  by  Dr.  John  H. 
McCollom,  City  Physician,  are  somewhat  more  favorable: 


140  DIPHTHERIA;    ITS   NATURE    AND    TREATMENT. 


Year. 

No.  of  Cases. 

No.  of  Deaths. 

of  Death 

1880 

1715 

588 

34.2 

1881 

1680 

601 

35.7 

1882 

1386 

458 

33.04 

1883 

1415 

445 

31.4 

1884 

1212 

345 

28.46 

1885 

1263 

334 

26.44 

1886 

1188 

329 

27.69 

1887 

1049 

316 

30.12 

Average 30.88 

It  is  justly  objected  to  the  conclusions  from  such  statistics 
that  not  all  the  cases  of  diphtheria  are  reported ;  but  in  view 
of  what  has  been  remarked  in  the  preceding  chapter  as  to  the 
unquestionable  frequency  of  errors  in  diagnosis,  it  is  very 
probable  that  the  deficiency  referred  to  has  been  at  least  com- 
pensated for  by  the  reporting  of  milder  forms  of  disease  as 
diphtheria.  In  23  of  the  1049  cases  reported  as  diphtheria  in 
Boston  in  1887,  the  error  in  diagnosis  was  so  palpable  as  to  be 
noted  by  the  Sanitary  Inspectors,  who  can  hardly  be  supposed 
to  have  been  hypercritical,  under  the  heading,  "  Mistake  in  the 
report  made  by  physicians."  * 

In  some  statistics  in  which  no  error  is  possible,  the  terrible 

fatality  of  the  disease  is  even  more  strikingly  indicated.    Thus, 

in  three  hundred  and  nineteen  cases  in  the  wards  of  the  Royal 

Charite  Hospital  in  Berlin,  reported  by  Henoch 2  in  1885,  two 

hundred  and  eight,  or  65.5  per  cent.,  were  fatal.    According  to 

the  statistics  of  the  Hospital  Trousseau,  Paris,  for  the  year 

1883,3  of  606  cases  of  diphtheria  treated,  391  died,  or  64.5  per 

cent.    On  the  other  hand,  medical  literature  abounds  in  reports 

of  large  numbers  of  cases  of  diphtheria,  some  of  which  will  be 

1 "  Report  of  the  Board  of  Health  of  the  City  of  Boston  for  1887,"  p.  25. 
2Charit6  Annalen,  vol.  x.,  p.  490. 

3  Archives   of  Paediatrics,  1884,  p.  321,  from   Rev.  Mens,  des  Mai.  de 
l'Enf.,  February,  1884. 


PROGNOSIS.  1-il 

subsequently  referred  to,  in  which  under  very  various  modes 
of  treatment  recovery  has  been  the  invariable  result  or  nearly 
so.  The  possible  sources  of  error  in  such  enumerations  are 
elsewhere  considered. 

The  estimate  is  probably  within  bounds  that  at  least  thirty 
per  cent,  of  all  cases  of  genuine  diphtheria  terminate  fatally, 
though,  of  course,  in  many  groups  of  cases  the  mortality  is 
very  much  less. 

In  so  far  as  the  prognosis  in  diphtheria  is  based  on  general 
conditions,  it  is  less  favorable  in  that  which  is  epidemic  than 
in  that  which  is  endemic  or  sporadic.  It  must  also  vary  ac- 
cording to  the  general  character  of  the  prevailing  epidemic, 
since  some  epidemics  are  much  more  severe  and  fatal  than 
others.  It  is  less  favorable  at  the  outset  or  the  height  of  an 
epidemic  than  during  its  decline.  It  is  less  favorable  in  the 
country  than  in  cities;  in  the  colder  seasons  of  the  year  than 
in  summer ;  in  insanitary  conditions  than  in  opposite  ones.  It 
is  also  in  the  same  degree  of  severity  of  the  disease  much  less 
favorable  in  the  cases  of  children  under  three  or  four  years  of 
age  than  of  older  patients. 

The  prognosis  in  a  case  of  diphtheria  must  at  its  onset  be 
a  guarded  one,  since  the  subsequent  extent  and  character  of 
the  disease  can  never  be  positively  predicted  from  the  symp- 
toms at  that  stage;  yet  severity  in  the  early  local  and  general 
manifestations  of  the  disease  is  of  comparatively  unfavorable 
prognostic  import,  while  mildness  is  correspondingly  favorable. 

Since  the  clangers  to  be  chiefly  apprehended  in  diphtheria 
are  two,  namely,  pseudo-membranous  obstruction  of  the  air- 
passages  and  constitutional  poisoning,  the  prognosis  must  be 
based  on  the  greater  or  less  tendency  of  the  disease  in  each 
particular  case  to  produce  one  or  the  other  or  both  of  these 
results. 

The  commencement  of  the  disease  in  the  larynx,  or  the 
subsequent  occurrence  of  the  symptoms  of  croup,  is  of  most 
unfavorable  portent.     When  no  symptom  of  the  extension  of 


142  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

the  disease  thither  has  appeared  by  the  third  day  from  the 
attack,  the  chances  of  escaping-  it  may  he  regarded  as  fair, 
and  they  improve  by  a  rapidly  increasing  ratio  with  each 
subsequent  day's  immunity,  until  the  sixth  or  seventh,  when 
they  may  be  regarded  as  very  favorable.  The  prognosis  in 
laryngeal  diphtheria  is  especially  unfavorable  when  the  symp 
toms  of  that  affection  are  accompanied  with  those  of  constitu- 
tional poisoning,  or  when,  either  before  or  after  tracheotomy 
or  intubation,  there  are  evidences  of  the  presence  of  bronchi 
tis,  tracheal  and  bronchial  diphtheria,  broncho-pneumonia, 
lobar  pneumonia  or  pulmonary  oedema. 

In  diphtheria  in  which  the  larynx  is  not  involved  the  prog- 
nosis is  unfavorable  in  direct  proportion  to  the  gravity  of  the 
local  affection,  as  manifested  in  the  intensity  of  the  inflamma- 
tion, and  the  extent  and  more  especially  the  depth  of  the 
pseudo-membranous  formation  and  its  occurrence  in  locations 
which  are  most  favorable  to  toxic  absorption. 

If  the  fever  which  was  high  at  the  outset  continues  high 
for  some  days,  or  if,  having  been  moderate,  it  becomes  persist- 
ently high,  its  significance  is  unfavorable,  because  it  denotes 
that  the  disease  is  severe  and  progressive  or  that  some  serious 
complication  exists.    . 

Adenitis  is  of  unfavorable  significance  in  proportion  to  its 
amount  and  the  rapidity  of  its  development. 

The  symptoms  which  have  been  elsewhere  described  as  es- 
pecially indicative  of  constitutional  diphtheritic  poisoning, 
such  as  pallor,  prostration,  somnolence,  anorexia,  etc.,  are  of 
bad  prognostic  import  in  proportion  to  their  gravity,  the 
earliness  and  rapidity  of  their  development  and  their  persist- 
ency in  spite  of  appropriate  treatment. 

Vomiting,  when  it  begins  and  continues  at  a  later  stage  of 
the  disease,  in  connection  with  marked  anorexia,  and  is  not 
merely  the  result  of  inappropriate  medication,  stimulation  or 
feeding,  is  an  evidence  of  profound  constitutional  poisoning 
and  is  a  bad  omen. 


PROGNOSIS.  143 

Marked  weakness  of  the  pulse  and  indistinctness  of  the 
heart-sounds  with  excessive  rapid  it}*  or  slowness,  especially 
when  accompanied  with  irregularit}-,  are  premonitory  or  indic- 
ative of  heart-failure.  Endocarditis  is  also  a  very  unfavora- 
ble complication. 

The  importance  of  albuminuria  varies  according-  to  its 
gravity  and  other  circumstances  which  have  been  stated  in 
the  chapter  on  symptoms. 

Delirium,  when  it  is  merely  the  accompaniment  of  high 
fever  in  the  earlier  stages  of  the  disease,  is  not  necessarily  of 
the  most  serious  import,  but  when  it  occurs  in  connection  with 
symptoms  of  grave  septic  and  ursemic  poisoning,  and  with 
other  evidences  of  resulting  meningeal  or  cerebral  implication, 
is  too  often  the  precursor  of  a  final  coma. 

Purpura  hemorrhagica  occurring  in  the  course  of  diphthe- 
ria is  usually  of  fatal  import. 

Gangrenous  diphtheria,  although  always  a  grave  form  of 
disease,  is  not,  under  suitable  treatment,  the  hopeless  one  which 
some  authorities  have  pronounced  it.  In  quite  a  number  of 
cases  which  have  been  included  in  my  experience  the  majority 
have  recovered, 

Nasal  diphtheria,  which  has  been  considered  by  some  good 
authorities  as  almost  necessarily  fatal,  may  under  suitable 
treatment  be  regarded  much  more  hopefully,  as  it  undoubtedly 
admits  of  cure  in  the  majority  of  all  cases.  The  danger  which 
it  involves  is  proportionate  to  the  amount  and  persistency  of  the 
pseudo-membranous  affection  of  the  nasal  passages,  and  to  the 
amount  of  constitutional  poisoning  which  has  already  taken 
place.  This  danger  is  markedly  increased  by  the  occurrence 
of  epistaxis,  which,  when  serious  and  persistent  is  a  most  un- 
favorable complication. 

When  the  various  local  and  general  manifestations  of  the 
disease  which  have  now  been  referred  to  take  place  with  that 
impetuous  and  overwhelming  rapidity  which  constitute  its 
malignant  form,  the  prognosis  is  grave  indeed. 


144  DIPHTHERIA;    ITS   NATURE    AND    TREATMENT. 

In  the  milcl  grade  of  diphtheritic  paralysis,  limited  mainhT 
to  the  soft  palate,  which  is  seen  in  the  large  majority  of  cases, 
the  prognosis  is  favorable  both  as  to  a  brief  duration  of  the 
attack  and  its  involving  no  serious  danger  to  life.  In  other 
cases  the  prognosis  in  respect  to  both  these  circumstances 
varies  according  to  the  severity  of  the  attack,  the  earliness 
with  which  it  follows  the  primary  disease,  and  the  parts  which 
it  affects.  When  the  initial  paralysis  of  the  palate  proves  to 
be  unusually  severe  and  persistent,  it  becomes  probable  that 
the  limbs  will  also  be  affected,  and  when  the  paresis  in  them 
is  especially  grave,  it  is  likely  that  the  upper  extremities  will 
not  escape.  Under  these  circumstances  the  duration  of  the 
attack  instead  of  from  two  to  six  weeks  will  be  as  many 
months.  As  a  general  though  not  an  invariable  rule  the  de- 
gree of  paralysis  is  in  some  direct  proportion  to  the  closeness 
of  its  sequence  to  the  primary  disease. 

Danger  to  life  from  diphtheritic  paralysis  is  proportionate 
to  the  degree  of  its  interference  with  heart  action,  respiration 
or  deglutition.  Definite  symptoms  of  cardiac  paralysis  occur- 
ring within  a  week  or  two  after  the  onset  of  diphtheria  are 
too  often  of  fatal  import.  The  danger  from  paralysis  of  the 
respiratory  muscles  is  greatest  when  both  the  intercostals 
and  the  diaphragm  are  affected.  Its  degree  is  in  proportion 
to  that  of  the  dyspnoea  and  of  the  accumulation  of  mucus  in 
the  bronchial  tubes.  In  serious  paralysis  of  the  pharynx  and 
the  larynx  there  are  the  dangers  of  inanition  from  the  diffi- 
culty of  swallowing  food  and  the  repugnance  to  attempting  it, 
and  of  suffocation  or  pneumonia  from  portions  of  food  entering 
the  air-passages. 


CHAPTER  X. 

PROPHYLAXIS. 

The  prophylaxis  of  diphtheria  must  consist  in  preventing, 
removing-,  or  avoiding-  as  far  as  possible  its  general  and  special 
causes.  These  have  been  referred  to  in  the  chapter  on  etiol- 
ogy- 
It  follows  that  in  selecting  a  residence  all  possible  care 
should  be  taken  to  avoid  the  conditions  which  predispose  to 
the  disease,  such  as  damp  situations,  unsusceptible  of  drain- 
age, the  vicinity  of  stagnant  and  polluted  water,  etc.  The 
greatest  attention  should  be  paid  to  preventing  the  contami- 
nation of  drinking-water.  Too  many  shade-trees  about  a  house 
are  undesirable,  and  every  pains  should  be  taken  to  secure  an 
ample  supply  of  sunlight  in  the  dwelling-rooms  as  well  as 
thorough  ventilation,  and  cleanliness  in  and  about  the  habita- 
tion. The  habitual  use  by  children  of  abundant  and  whole- 
some food  is  of  great  importance.  Since  many  attacks  of 
diphtheria  follow  catching-  cold  the  greatest  attention  should 
be  paid  to  the  suitable  dressing  of  children,  the  prevention  of 
damp  feet,  etc.  Careful  attention  must  also  be  paid  to  the 
ventilation,  warming  and  general  sanitary  condition  of  the 
school-houses  which  they  attend. 

vThe  securing  of  the  enactment  of  proper  sanitary  regula- 
tions in  towns  and  villages  and  their  faithful  enforcement  by 
the  authorities  should  be  regarded  as  a  most  important  duty 
by  every  citizen.  The  removal  of  the  conditions  which  favor 
disease,  such  as  overcrowding,  filth,  etc.,  from  the  tenement- 
houses  and  hovels  of  the  poor,  might  prevent  many  an  epi- 
10 


146  DIPHTHERIA;    ITS   NATURE    AND   TREATMENT. 

demic  which  from  those  sources  invades  and  devastates  the 
homes  of  the  more  fortunate  classes. 

During-  the  prevalence  of  an  epidemic,  especial  attention 
should  be  paid  to  everything-  which  relates  to  the  health  of 
children.  Their  throats  should  be  frequently  inspected.  Their 
colds  and  catarrhs  should  receive  prompt  treatment.  It 
should  be  remembered  that  decaying  teeth  and  coated  tongues 
may  furnish  a  nidus  for  disease-germs.  If  there  is  a  tendency 
to  relaxed  conditions  of  the  mucous  membranes  the  mouth 
and  throat  may  be  frequently  washed,  gargled  or  sprayed,  or 
the  nasal  passages  syringed  or  sprayed  with  some  mild  anti- 
septic and  astringent  liquid  such  as  will  be  mentioned  in  the 
next  chapter.  Depressed  conditions  of  the  general  health 
should  be  promptly  corrected  by  the  use  of  suitable  tonics, 
especially  iron.  At  such  times,  also,  the  greatest  vigilance 
should  be  used  by  teachers,  parents  and  the  public  authorities 
to  prevent  the  introduction  of  the  disease  into  schools  or  to 
ensure  its  prompt  recognition  should  that  occur. 

When  a  case  of  the  disease  occurs  in  a  family,  the  patient 
should  at  once  be  strictly  isolated — preferably  in  a  room  at 
the  top  of  the  house,  which  should  be  capable  of  free  ventila- 
tion  and  exposed  to  direct  sunlight.  All  unnecessary  furni- 
ture, especially  hangings  and  upholstery,  should  first  be  re- 
moved from  it.  Should  there  be  reason  to  suspect  unfavorable 
endemic  conditions,  the  well  children  should,  if  practicable, 
be  sent  away  until  the  danger  of  infection  is  over.  In  any 
case  they  should  be  kept  under  the  vigilant  supervision  of  a 
physician.  Their  throats  should  be  inspected  twice  daily,  and 
the  preventive  local  and  general  measures  just  referred  to 
should  be  promptly  employed  when  indicated.  I  have,  in 
many  cases  of  children  who  had  been  exposed  to  the  contagion 
of  diphtheria,  or  were  continuously  exposed  to  it,  directed  that 
the  tincture  of  iron  mixture  or  that  of  iron  and  the  chlorate  of 
potassa,  of  which  the  formulas  will  be  given  in  the  next  chap- 
ter, should  be  administered   every  two  or  three  hours,  and 


PROPHYLAXIS.  147 

have  had  reason  to  think  that  the  result  has  been  advan- 
tageous. 

Nurses  who  attend  upon  the  sick  should  he  kept  isolated 
from  the  children  of  the  household. 

The  danger  of  the  emanation  of  diphtheritic  poison  from 
the  sick  and  the  consequent  infection  of  others  will  be  greatly 
diminished  by  the  employment  of  the  local  antiseptic  treat- 
ment of  the  disease,  which  will  be  described  in  the  next  chap- 
ter, and  of  thorough  measures  of  cleanliness,  ventilation,  etc. 
The  records  of  201  dispensary  cases,  including  many  very 
severe  ones,  thus  treated  by  me,1  in  which  little  or  no  separa- 
tion of  the  sick  from  the  well  was  practicable,  show  that  2 
occurred  together  or  consecutively  in  the  same  family  in  eigh- 
teen instances,  3  in  five  instances,  and  6  in  one  instance,  while 
144  were  solitary  cases  subsequently  to  the  commencement  of 
antiseptic  treatment,  although  not  a  few  of  them  had  been 
preceded  by  other  cases  under  other  treatment. 

In  case  of  death  from  the  disease  the  corpse  should  be 
placed  in  an  air-tight  casket,  the  burial  take  place  promptly 
and  the  funeral  be  strictly  private. 

The  following  are  from  the  "  Instructions  for  Disinfection  " 
issued  by  the  Health  Department  of  this  city  in  1888: 

I.  Disinfectants  to  be  Employed. 

1.  Roll  Sulphur  (brimstone)  for  fumigation. 

2.  Sulphate  of  Zinc  and  Common  Salt  dissolved  together  in 
the  proportion  of  four  ounces  of  the  former  and  two  ounces  of 
the  latter  in  a  gallon  of  water;  for  clothing,  bed-linen,  etc. 

3.  Sulphate  of  Iron  (copperas)  dissolved  in  water  in  the 
proportion  of  one  and  one  half  pounds  to  the  gallon;  for  soil, 
sewers,  etc. 

4.  Corrosive  Sublimate  Solution.  Made  by  dissolving  bi- 
chloride of  mercury  in  the  proportion  of  eight  grains  to  the 

1  See  New  York  Medical  Record,  April  9th,  1887,  p.  399. 


118  diphtheria;  its  nature  and  treatment. 

pint  of  water.     To  the  discharges  of  a  sick  person  should,  he 
added  an  equal  quantity  of  the  solution. 

II.  How  to  Use  Disinfectants. 

1.  The  clothing,  towels,  etc.,  should,  on  removal  from  the 
patient,  and  hefore  they  are  taken  from  the  room,  he  placed  in 
a  pail  or  tub  of  the  zinc  solution,  boiling  hot.  All  discharges 
should  be  received  in  vessels  containing  the  corrosive  subli- 
mate or  the  copperas  solution.  When  that  is  impracticable 
they  should  be  covered  immediately  with  the  solution.  All 
vessels  used  about  the  patient  should  be  cleansed  with  the 
solution. 

2.  For  fumigation  the  rooms  to  be  disinfected  must  be 
vacated,  and  closed  as  tightly  as  possible,  stopping  up  chim- 
neys, ventilators,  etc.  Place  the  sulphur  in  iron  pans  sup- 
ported upon  bricks  placed  in  wash-tubs  containing  a  little 
water ;  set  it  on  fire  by  means  of  hot  coals  or  with  the  aid  of  a 
little  alcohol  poured  over  it.  Allow  the  room  to  remain 
closed  for  twenty-four  hours;  then  open  all  windows  and  air 
thoroughly. 

Heavy  clothing,  bedding  and  other  articles  which  cannot 
be  treated  with  the  zinc  solution  should  be  hung  in  the  room 
during  the  fumigation,  their  surfaces  thoroughly  exposed. 
Care  should  be  taken  to  have  woolen  and  cotton  goods  free 
from  moisture,  or  the  sulphur  fumes  will  injure  them. 
Pockets  should  be  turned  inside  out.  Afterwards  the  articles 
should  be  hung  in  the  open  air,  and  thoroughly  beaten  and 
shaken. 

Pillows,  beds,  upholstered  furniture,  etc.,  should  be  cut  open, 
the  contents  spread  out  and  fumigated.  Carpets  are  best 
fumigated  on  the  floor,  but  should  afterwards  be  removed  to 
the  open  air  and  thoroughly  beaten. 

For  fumigation  at  least  three  pounds  of  sulphur  should  be 
used  for  every  thousand  cubic  feet. 

3.  Body  and  Bed  Clothing',  etc. — It  is  best  to  burn  all  arti- 


PROPHYLAXIS.  149 

cles  which  have  been  in  contact  with  persons  sick  with  conta- 
gious or  infectious  diseases.  Articles  too  valuable  to  be  de- 
stroyed should  be  treated  as  follows : 

(a)  Cotton,  linen,  flannels,  etc.,  should  be  treated  with  the 
boiling-hot  zinc  solution.  Introduce  piece  by  piece  to  secure 
thorough  wetting,  and  boil  for  at  least  half  an  hour. 

(b)  Heavy  clothing,  etc.,  should  be  treated  as  described 
under  the  directions  for  fumigation. 

4.  Water-closets,  privies,  sewers,  etc.,  should  be  frequently 
and  liberally  treated  with  copperas  solution. 

At  a  meeting  of  the  Michigan  State  Medical  Society l  the 
secretary  demonstrated  in  a  tabulated  statement  accompanied 
with  a  graphic  chart  the  extent  to  which  isolation  and  disin- 
fection had  reduced  the  number  of  cases  of  diphtheria  and  the 
number  of  deaths  therefrom  in  the  various  outbreaks  reported 
by  local  health-officers  during  the  year  1886.  In  102  outbreaks 
in  which  there  was  a  neglect  of  one  or  both  of  these  measures, 
the  average  number  of  cases  to  the  outbreak  was  a  little  over 
16,  and  the  average  number  of  deaths  3.23;  while  in  116  out- 
breaks in  which  both  were  enforced  the  average  number  of 
cases  was  2.86,  and  that  of  deaths  0.66.  In  other  words  these 
simple  precautions  reduced  the  number  of  cases  occurring 
during  the  year  by  1545,  and  the  number  of  deaths  by  298. 


New  York  Medical  Journal,  May  21,  1887,  p.  580. 


CHAPTER  XI. 

TREATMENT. 

General  Indications. 

The  factors  which  are  to  be  dealt  with  in  the  treatment  of 
diphtheria  are,  as  has  already  been  seen: 

1.  A  parasite  which  is  implanted  on  or  in  the  mucous  mem- 
brane or  other  affected  surface,  and  there  produces  the  poison 
which  causes  the  disease. 

2.  A  specific  inflammation  which  is  excited  thereby,  and 
which  has  the  two  folio  wing  results : 

(a)  The  reproduction  and  local  dissemination  of  the  poison, 
and 

(b)  The  production  of  a  false  membrane  which,  though 
itself  inert,  does  harm  in  two  ways,  namely,  by  shutting  in  the 
poison  and  preventing  its  removal  and  thus  favoring  its  ab- 
sorption, and  also  in  certain  situations  by  interfering  mechan- 
ically with  vital  functions,  especially  respiration. 

3.  The  absorption  of  the  poison  or  poisons  into  the  circula- 
tion, and  the  production  thereby  of  a  general  disease  which  is 
characterized  by  a  tendency  to  adynamia  and  the  occurrence 
of  various  organic  lesions. 

The  principal  general  indications  which  have  to  be  met  in 
the  treatment  of  diphtheria,  are,  therefore,  the  following : 

1.  To  destroy,  remove,  or  limit  the  action  of  the  invading 
poison.  Measures  for  this  purpose  include  the  employment  of 
a  great  variety  of  agents  and  processes  for  local  disinfection 
and  for  the  removal  of  the  false  membrane  and  also  of  inter- 
nal medication  to  promote  the  same  objects. 


TREATMENT.  151 

2.  To  subdue  or  limit  the  inflammation.  Measures  for  this 
purpose  are  both  local  and  general. 

3.  To  obviate  the  occlusion  of  the  air-passages  by  false 
membrane.  Measures  for  this  purpose  are  surgical  and  me- 
chanical. 

4.  To  promote  the  elimination  and  counteract  the  effects  of 
poison  which  may  have  been  absorbed. 

5.  To  economize  and  sustain  the  vital  forces  in  their  com- 
bat with  the  disease. 

6.  To  avert  or  combat  the  morbid  effects  of  the  disease 
upon  particular  organs,  and  other  special  dangers  which  may 
in  any  case  arise  during  its  course. 

General  Principles  of  Treatment. 

The  practicability  and  the  relative  importance  of  each  of 
these  indications,  and  the  choice  of  means  for  its  accomplish- 
ment, vary  in  different  cases  according  to  many  circumstances, 
among  which  are  the  type,  the  stage,  and  the  localization  of 
the  disease  and  the  age  and  constitution  of  the  patient.  No 
merely  routine  method,  therefore,  can  be  indiscriminately 
employed,  but  the  treatment  must  be  intelligently  adapted  to 
the  circumstances  in  each  particular  case. 

The  fulfilment  of  the  first  and  most  obvious  of  the  indica- 
tions just  enumerated  is  in  practice  opposed  by  difficulties 
which  are  often  grave  and  sometimes  insuperable,  arising 
from  the  inaccessible  location  of  the  affection  in  many  cases, 
the  opposition  made  to  our  efforts  by  young  children,  and  the 
fact  that  the  parasite  which  causes  the  disease,  except  in  its 
mildest  forms  and  earliest  stages,  lies  not  merely  on  the 
affected  surfaces,  but  within  their  more  superficial  tissues  and 
in  inaccessible  recesses,  while  in  not  a  few  instances  complica- 
ting septic  organisms  have  become  widely  distributed  through 
the  system.  In  such  cases  successful  efforts  at  local  disinfec- 
tion must  often  be  limited  to  diminishing  in  some  degree  the 
growth  and  vital  activity  of  the  pathogenic  organisms  rather 


152  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

than  their  eradication,  to  softening-  and  thinning  the  false 
membranes  rather  than  their  complete  destruction,  and  to 
diluting  and  washing  away  some  portion  only  of  the  chemical 
poison  of  the  disease,  and  thus  diminishing,  though  not  en- 
tirely preventing,  its  absorption.  When  the  disease  in  its 
grave  forms  is  once  fully  established,  it  cannot,  in  the  ma- 
jority of  cases,  be  cut  short.  Its  "cure"  must  often  con- 
sist in  checking  to  the  utmost  possible  degree  its  dangerous 
tendencies  and  sustaining  the  strength  of  the  patient  until  the 
malady  ceases  by  self -limitation. 

The  fact  that  diphtheritic  inflammation  is  characterized 
by  an  extreme  liability  to  be  aggravated  by  any  extraneous 
irritation,  and  that  such  aggravation  of  the  inflammation  in- 
evitably involves  the  increase  and  intensification  of  the  disease, 
forbids  the  use  of  all  harsh  measures  that  are  not  absolutely 
necessary,  and  requires  the  utmost  possible  gentleness  in  all 
manipulations  and  medication. 

The  fact  that  the  tendency  of  the  disease  is  to  asthenia  re- 
quires the  careful  avoidance  of  all  unnecessarily  weakening, 
harassing  or  fatiguing  measures. 

It  follows  that,  especially  in  the  treatment  of  young  chil- 
dren, who  constitute  a  large  proportion  of  our  patients  in  this 
disease,  it  is  of  the  greatest  importance  to  avoid  all  medication 
which  is  so  unpleasant  to  the  taste  or  so  painful  to  the  sensi- 
tive throat  as  to  arouse  repugnance  and  opposition,  and  thus 
occasion  a  series  of  exhausting  struggles.  Not  a  little  treat- 
ment which  has  been  excellent  in  intention  and  sound  in  prin- 
ciple, has  been  rendered  futile  or  even  worse  than  no  treat- 
ment at  all  by  having  precisely  this  effect. 

The  application  of  this  principle  makes  it  necessarj^  to  omit 
some  methods  of  treatment  in  the  cases  of  young  children, 
which  are  practicable  and  very  valuable  in  those  of  older 
patients. 

On  the  other  hand,  it  is  important  to  remember  that  the 
insidious  and  dangerous  character  of  diphtheria  demands  the 


TREATMENT.  153 

utmost  promptitude  and  decision  in  combating-  it.  Measures 
which  are  essentially  unpleasant  but  necessary  must  be  inflex- 
ibly carried  out.  Everything-  depends  in  many  cases  on  the 
earliness  with  which  efficient  measures  are  employed. 

While  the  theory  of  the  treatment  of  diphtheria  consists  in 
the  application  of  certain  broad  and  easily  understood  princi- 
ples, its  successful  practice  requires  the  closest  attention  to 
details — many  of  them  apparently  trivial.  This  in  all  severe 
cases  includes  the  necessity  of  very  frequent  visits  on  the  part 
of  the  physician,  and  the  careful  instruction  of  parents  and 
nurses. 

The  successful  treatment  of  diphtheria  not  only  demands 
a  careful  adaptation  of  measures  to  each  particular  case,  but 
often  especially  requires  a  patient  persistency  in  the  use  of 
well-selected  ones.  Under  the  best  treatment  there  must 
often  be  a  succession  of  anxious  days  in  which  little  or  no  pos- 
itively curative  impression  seems  to  be  made  upon  the  mal- 
ady. Impatience,  indecision,  and  changes  of  method  without 
definite  reason,  are  but  too  liable  in  the  battle  with  this  dis- 
ease, as  in  other  conflicts,  to  invite  defeat. 

The  Results  of  Treatment. 

The  test  of  the  value  of  therapeutical  measures  is  their 
results.  Yet  an  accurate  estimate  of  those  results  in  the 
treatment  of  diphtheria  is  extremely  difficult.  This  difficulty 
arises  mainly  from  two  causes : 

1.  The  great  differences  in  inherent  tendency  to  a  favora- 
ble or  a  fatal  issue  in  different  cases  of  diphtheria  according 
to  their  type  (as  benign,  severe  or  malignant),  their  localiza- 
tion (as  laryngeal,  nasal  or  pharyngeal),  according  as  they  are 
sporadic  or  epidemic,  and  according  to  the  widely  varying 
character  of  different  epidemics.  The  records  of  mortality 
from  the  disease  under  the  same  or  similar  modes  of  treat- 
ment vary  from  this  cause  between  the  most  remote  extremes. 

2.  The  confusing  character  of  such  records  is  greatly  in- 


154  diphtheria;  its  nature  and  treatment. 

creased  by  the  frequenc}^  of  errors  in  diagnosis.  Dr.  L.  E.  Holt * 
well  says,  "  Our  journals  are  continually  filled  with  new  spe- 
cifics, accompanied  with  an  enumeration  of  cases  in  which  they 
have  been  successful.  When  detailed  reports  of  cases  are 
given,  it  is  evident  from  a  critical  examination  of  them  that 
the  great  number  of  them  are  not  cases  of  diphtheria  at  all, 
while  the  universality  of  the  successes  claimed  by  others  is  a 
sufficient  proof  of  the  worthlessness  of  their  observations.  It 
must  be  evident  to  any  one  who  attempts  to  keep  up  with  the 
literature  of  the  subject,  that  before  any  great  advances  can 
be  made  in  the  treatment  of  diphtheria  we  must  insist  on 
greater  exactness  in  its  diagnosis." 

It  may  be  conducive  to  a  just  estimate  of  the  value  of  re- 
ports of  therapeutical  results  in  this  disease  to  consider  for  a 
moment  what  results  from  treatment  can  rationally  be  ex- 
pected. All  cases  of  true  diphtheria  may  be  divided  into  three 
classes,  namely  (1),  those  which  would  recover  without  any 
medical  treatment;  (2),  those  which  will  terminate  fatally 
under  any  treatment  at  present  known,  and  (3),  those  the 
issue  of  which  depends  on  the  treatment  employed.  Any  at- 
tempt to  fix  the  proportion  of  these  three  classes  must  of 
course  in  the  absence  of  data  be  in  a  large  degree  conjectural. 
I  shall  venture  in  this  sense  to  estimate  the  first  class  at  forty- 
five  per  cent,  of  all  cases;  the  second  at  ten  per  cent.,  and  the 
third  again  at  forty-five  per  cent.,  though  this  last  percentage 
is  practically  diminished  and  the  second  increased  by  the  fact 
that  in  all  large  numbers  of  cases  a  considerable  proportion 
come  under  the  care  of  the  physician  too  late  for  treatment  to 
be  effective.  It  is  evident,  even  without  assuming  the  accu- 
racy of  these  estimates,  that  the  distribution  of  these  three 
classes,  especially  in  small  series  of  cases,  may  be  so  different 
that  apparently  very  favorable  or  very  unfavorable  results  of 
treatment  may  be  largely  accidental. 

By  the  law  of  averages,  the  liability  to  this  source  of  error 
1  Trans,  of  the  Med.  Soc.  of  the  State  of  New  York,  1886,  p.  553. 


TREATMENT.  155 

is  greatly  diminished  in  large  numbers  of  cases,  but  even  such 
statistics  are  worthless  if  there  is  room  for  doubt  as  to  the 
correctness  of  the  diagnosis.  It  follows  that  all  statistical 
contributions  to  the  therapeutical  literature  of  diphtheria,  in 
order  to  be  of  authoritative  value,  should  not  only  accurately 
describe  the  methods  of  treatment  employed,  but  should  also 
be  accompanied  with  such  descriptions  of  the  cases  referred 
to  as  will  place  it  beyond  doubt,  not  only  that  they  were  gen- 
uine cases  of  diphtheria,  but  also  to  what  forms  and  types  of 
the  disease  they  belonged.  By  such  painstaking  methods 
only  can  the  requisite  data  be  furnished  for  a  reliable  system 
of  therapeutics  in  this  disease. 

The  Modes  of  Employing  Remedies. 

1.  Internal  Administration. — This  is  not  only  the  usual 
method  of  employing  remedies  for  constitutional  effect,  bub  is 
also  one  of  the  most  important  modes  of  their  local  applica- 
tion. For  the  latter  purpose  it  has  the  advantages  of  sim- 
plicity and  easy  availability,  and  important  and  obvious  lim- 
itations as  to  the  class  of  medicinal  agents  to  which  it  is 
adapted,  and  the  surfaces  which  it  reaches. 

2.  Gargling. — This  method  is  not  only  unavailable  in  the 
cases  of  young  children,  but  even  in  those  of  older  patients  its 
frequent  employment  in  diphtheria  is  unpleasant  and  fatigu- 
ing. It  is  moreover  in  many  cases  inefficient,  from  the  reme- 
dies so  employed  not  freely  reaching  the  posterior  part  of  the 
pharynx.  It  is  therefore  in  most  cases  inferior  to  the  two 
methods  next  to  be  mentioned. 

3.  Spraying. — This  method  has  the  advantages  of  being 
gentle  and  unirritating,  and  not  very  fatiguing,  and  that  by  it 
remedies  may  be  applied  in  a  more  direct,  evenly  diffused  and 
continuous  manner  to  the  oral  and  pharyngeal  surfaces  than 
by  most  other  methods,  and  may  even  by  the  aid  of  the  in- 
spired air  be  made  to  reach  the  rima  glottidis  and  the  vocal 
cords.     It  is  important  to  remember  that  if  the  spray  is  too 


156  diphtheria;   its  nature  and  treatment. 

coarse  and  too  forcibly  driven  its  effect  may  be  irritating-. 
This  method  is  advantageous  only  when  the  fluids  so  used 
reach  the  affected  surfaces  as  spray.  It  is  efficient  in  the 
throat  only  when  the  mouth  is  widely  opened  or  the  tongue  is 
depressed.  Its  frequent  use,  therefore,  requires  the  voluntary 
cooperation  of  the  patient,  and  is  unfortunately  not  practicable 
in  most  cases  of  children  under  three  years  of  age.  For  rea- 
sons which  will  be  referred  to  in  speaking  of  the  treatment  of 
nasal  diphtheria,  it  is  in  most  cases  less  available  in  that  con- 
dition than  the  method  next  to  be  mentioned. 

4.  Irrigation. — This  may  be  effected  by  means  of  a  syringe, 
of  the  piston,  hand-ball  or  fountain  variety.  The  first  is  usually 
preferable.  It  is  a  very  important  and  valuable  method  of 
cleansing  affected  surfaces  and  applying  suitable  remedies  to 
them.  It  is,  however,  important  that  it  be  employed  with  the 
utmost  gentleness  which  is  consistent  with  its  efficiency,  as 
otherwise  its  effect  may  be  irritating  and  injurious.  Its  spe- 
cial applicability  is  to  the  nasal  passages,  and  to  the  throat  in 
the  cases  of  children  too  young  to  be  sprayed. 

5.  Vaporization  and  Inhalation. — This  method  has  obvi- 
ous advantages  for  the  introduction  of  certain  substances  into 
the  system  for  constitutional  effect,  and  also  for  bringing  them 
into  direct  contact  with  the  otherwise  inaccessible  mucous 
membranes  of  the  air-passages.  Its  most  important  limita- 
tion is  the  danger  of  its  interference  with  the  purity  or  respi- 
rability  of  the  air. 

6.  Insufflation. — The  application  of  certain  substances  to 
directly  accessible  surfaces  in  the  form  of  powder  has  obvious 
advantages.  Substances  so  applied  are  liable  to  be  irritating 
in  direct  proportion  to  their  insolubility  and  the  coarseness  of 
the  powder. 

7.  Application  by  means  of  a  brush,  pencil,  or  sivab. — 
.This  method  has  the  advantages  of  precision  and  accurate 

limitation.  It  is  therefore  specially  adapted  to  the  application 
of  concentrated  and  irritating  substances.     Its  use  is  contra- 


TREATMENT.  157 

indicated  for  other  than  directly  accessible  surfaces,  and,  as  a 
general  rule,  in  the  cases  of  young-  children. 

Various  details  in  these  modes  of  employing'  remedies  will 
be  more  appropriately  spoken  of  elsewhere. 

Caustics. 

Aretaeus  advocated  the  employment  of  caustics  in  the  fol- 
lowing words:  "Utile  fuerit,  igitur,  partem  affectam  igne 
adurere,  sed  factu  temerarium  utpote  in  tarn  angusto  faucium 
loco;  quam  ob  rem  medicamentis  igni  simillibus  utendum 
est." » 

Bretonneau  obtained  " favorable  results "  and  "cures"  by 
the  local  application  of  concentrated  hydrochloric  acid,  either 
diluted  with  three  parts  of  honey,  or,  later  and  preferably, 
pure,  the  object  and  effect  being  to  "substitute  another  in- 
flammation in  order  to  arrest  that  which  is  specific."  Recog- 
nizing the  danger  of  harsh  applications,  Bretonneau  limited 
its  employment  as  follows :  "  When  the  disease  is  not  arrested 
by  two  energetic  applications  made  at  an  interval  of  twenty- 
four  hours  it  would  be  imprudent  not  to  abandon  it." 

The  employment  of  nitrate  of  silver  having  been  introduced 
by  Dr.  Mackenzie,2  of  Glasgow,  Bretonneau,  in  his  fifth 
memoir,  stated  that  he  had  found  it  less  painful  and  more 
efficacious  than  hydrochloric  acid.  He  employed  the  solid 
stick  and  a  sponge  moistened  with  a  strong  solution.  He 
stated  that  when  the  treatment  is  commenced  on  the  first  day 
of  the  disease  (two  applications  being  made  daily)  "  a  radical 
cure  may  be  obtained  in  forty-eight  hours,"  but  that  "  every 
hour  and  every  day  the  necessity  of  a  more  active  and  pro- 
longed treatment  goes  on  increasing  in  melancholy  propor- 
tion." 

That  the  practice  of  Bretonneau  was  attended  with  very 

1  It  would  be  useful  to  burn  the  affected  part  with  fire,  but  a  rash 
practice  on  account  of  the  narrowness  of  space  in  the  fauces ;  for  which 
reason  medicaments  similar  to  fire  must  be  employed. 

2  Med  and  Surg.  Journ.,  vol.  xxiii.,  p.  294. 


158  diphtheria;  its  nature  and  treatment. 

favorable  results  is  evident  even  from  his  modest  statements. 
For  instance,  he  mentions  that  on  one  occasion  when  he  was 
summoned  by  the  Minister  of  War  to  the  Ecole  Militaire,  on 
account  of  an  epidemic  of  malignant  angina  which  had  shown 
an  alarmingly  fatal  character,  he  treated  sixty  of  the  pupils 
who  were  suffering  from  the  disease  at  a  more  or  less  ad- 
vanced stage  with  a  favorable  result  in  every  case. 

In  laryngeal  diphtheria  the  moistened  sponge  was  applied 
to  the  glottis,  the  epiglottis  being  held  up  by  a  spatula.  The 
result  was  that  in  some  cases  the  false  membrane  was  expec- 
torated and  the  necessity  for  tracheotomy  obviated,  a  cure 
resulting  on  the  fifth  or  sixth  day.  Similar  results  in  his  own 
practice  and  in  that  of  his  fellow  practitioners  were  reported 
by  Mackenzie,  of  Glasgow,  and  also  by  Gendron,1  Girouard,2 
Bouchut,3  Velpeau,4  Geddings,5  and  many  others.  Trousseau 
practiced  and  recommended  cauterization  with  the  substances 
just  referred  to,  and  also  with  cupric  sulphate  in  saturated 
solution,  and  the  acid  nitrate  of  mercury.  Other  caustics 
which  have  been  employed  in  the  treatment  of  diphtheria  are 
nitric,  sulphuric,  chromic  and  strong  carbolic  acid  and  caustic 
soda  and  potash.  With  the  exception  of  carbolic  acid,  which 
may  sometimes  be  advantageously  used  either  pure  or  diluted 
with  equal  parts  of  glycerine  or  water,  their  action  is  both 
painful  and  dangerous. 

The  use  of  the  actual  cautery  during  an  epidemic  of  diph- 
theria in  1828  by  Dr.  Bonsergent,  who  thrust  a  red-hot  iron 
into  the  diphtheritic  throats  of  children,  is  described  by  Trous- 
seau,6 who  "  witnessed  some  successful  results  "  of  this  danger- 
ous procedure.  Trousseau  employed  it  himself,  but  only  in 
cutaneous  and  vulvar  or  oral  diphtheria. 

1  Journ.  compl.  du  Diction,  des  Sc.  M6d.,  t.  xxiii.,  p.  346. 

2  Journ.  Gen.  de  M6d.,  t.  ciii.,  p.  305. 

3"  Traits  pratique  des  Malad.  des  Nouveaux  Nes,"  etc.,  1852. 

"Gaz.  M6d.,  1830,  p.  11. 

6  Amer.  Journ.  of  the  Med.  Sc,  vol.  xxiv. 

6  Clinical  Medicine,  vol.  ii. 


TREATMENT.  159 

The  use  of  caustics  was  in  some  cases  attended  with  deplor- 
able accidents  and  fatal  results,  which  called  forth  protests 
against  their  employment  from  Archambault-Reverdy *  and 
many  subsequent  writers.  Moreover,  the  spread  of  the  belief 
in  the  primarily  constitutional  rather  than  local  nature  of 
diphtheria  contributed  not  a  little  to  their  gradual  and  almost 
universal  disuse.  The  use  of  nitrate  of  silver  has,  however, 
always  had  its  adherents.  Dr.  T.  J.  Hutton 2  of  Fergus  Falls, 
Minnesota,  for  instance,  applies  lunar  caustic  in  solution  in  the 
strength  of  from  twenty  to  fifty  grains  to  the  fluid  drachm  of 
water  with  a  camel's  hair  brush  once  or  twice  daily  so  long  as 
membrane  continues  to  form.  He  states  that,  in  209  cases 
thus  treated  by  him  only  twelve  have  died. 

Among  the  caustic  agents  which  have  been  referred  to,  the 
nitrate  of  silver  is  least  open  to  certain  objections  and  has 
special  limitations.  Its  action  is  comparatively  superficial. 
It  is  one  of  the  least  irritating  of  caustics.  Locally  it  causes 
greater  contraction  of  the  vessels  than  other  metals.  (Brun- 
ton.)  It  combines  with  albumen  and  destroys  or  imprisons 
parasitic  fungi  which  are  exposed  to  its  action.  Its  utility  as 
a  caustic  in  diphtheria  is  therefore  limited  to  the  earlier  stages 
and  the  more  superficial  forms  of  the  disease. 

The  use  of  the  actual  cautery  has  been  revived  in  the  form 
of  the  galvano-cautery,  by  Dr.  Tedeschi 3  and  by  Dr.  Bloebaum.4 
This  treatment  was  first  employed  by  the  latter  in  many  cases 
of  diphtheria  in  young  pigeons  and  subsequently  in  a  number 
of  cases  of  human  diphtheria.  Besides  gargles  of  ice-water  no 
other  treatment  was  employed.  Prof.  Henoch,5  of  Berlin,  also 
employed  this  method  in  a  grave  case  of  diphtheria  with  a 
favorable  result. 

The  use  of  the  galvano-cautery  is  described  as  painless. 

1  Journ.  Univ.  des.  Sc.  MM.,  t.  lvii.,  p.  257. 

2  New  York  Med.  Rec,  April  9,  1887,  p.  417. 
3Rivista  Venet.,  Nov.,  1885. 

4  Verhandl.  d.  Cong.  f.  innere  Med.,  Wiesbaden,  1886,  V.  432. 
b  Therapeutic  Gazette,  1886,  p.  603. 


160  diphtheria;  its  nature  and  treatment. 

At  its  mere  touch  the  false  membrane  rolls  up  and  falls  off. 
It  is  not  reformed  nor  does  the  diphtheritic  process  extend. 
The  fever  and  the  glandular  swelling-  rapidly  subside.  The 
slough  which  it  causes  comes  away  in  eight  to  fourteen  days, 
leaving  a  healthy  ulcer. 

Even  after  making  all  due  allowance  for  mistakes  in  diag- 
nosis and  other  sources  of  error,  the  evidence  which  has  now 
been  referred  to  seems  to  be  conclusive  to  the  effect  that  the 
application  of  caustics  in  the  early  stage  of  diphtheria  has  in 
not  a  few  instances  cut  short  the  disease,  preventing  its  local 
development  and  its  constitutional  manifestations.  This  fact 
is  of  great  interest  and  importance  as  adding  confirmation  to 
the  view  of  the  primarily  local  nature  of  diphtheria  which  has 
been  maintained  in  this  work,  and  is  full  of  suggestiveness  as 
to  the  direction  which  should  be  given  to  future  efforts  to  per- 
fect the  therapeutics  of  the  disease,  especially  in  its  early 
stages.  It  cannot  be  denied  that  the  application  of  powerful 
caustics  in  diphtheria  is  open  to  grave  objections  and  is  at 
best  subject  to  great  and  important  limitations.  The  theory 
of  their  use  is  the  destruction  of  the  specific  character  of  the 
inflammation.  It  is  evident,  however,  that  if  they  fail  to  com- 
pletely accomplish  this  object,  the  inflamed  and  necrosed  tis- 
sues caused  by  their  use  must  become  an  especially  favorable 
soil  for  the  occupation  of  the  diphtheritic  virus,  and  the  result 
is  liable  to  be  an  aggravation  of  the  disease.  Since  the  utility 
of  cauterization  is  mainly  restricted  to  the  early  stage  of  the 
disease,  and  to  cases  in  which  it  is  definitely  limited  to  easily 
accessible  locations,  its  employment  is  under  any  circum- 
stances practically  excluded  in  a  large  proportion  of  the  worst 
cases  with  which  we  have  to  deal.  Since,  moreover,  it  is  liable 
to  be  more  or  less  painful,  is  in  its  verj^  nature  calculated  to 
inspire  dread,  is  difficult  or  impossible  of  safe  execution  in  the 
cases  of  young  children,  and,  moreover,  when  employed  inju- 
diciously or  clumsily  is  liable  to  produce  disastrous  results,  it 
is  not  probable  that  the  verdict  of  the  profession,  which  has 


TREATMENT.  161 

consigned  it  to  almost  complete  disuse,  will  ever  be  to  any 
great  extent  reversed.  Other  and  less  hazardous  means  of 
accomplishing-  the  same  ends  will  continue  to  he  sought  for. 

Astringents. 

Astringents  are  especially  valuable  in  the  presence  of  great 
swelling  of  the  tonsils  and  uvula,  relaxed,  ulcerated  or  haemor- 
rhagic  conditions  of  the  mucous  membrane  and  profuse  secre- 
tions. 

The  astringents  which  have  been  principally  employed  in 
the  treatment  of  diphtheria  are  alum,  tannin,  the  liquor  ferri 
subsulphatis  and  the  chloride  of  iron. 

The  use  of  alum  and  of  tannin  (in  the  form  of  powdered 
nut-galls)  was  recommended  by  Areteeus.  The  former  was 
used  by  Bretonneau,  and  both  by  Trousseau.  Powdered  alum 
has  been  much  used  by  being  blown  into  the  throat  through  a 
tube  or  by  means  of  an  insufflator.  Trousseau  employed  in 
this  way  from  one  to  two  grammes  at  each  application,  which 
he  caused  to  be  repeated  from  four  to  ten  times  in  the  twent}'- 
four  hours.  He  advised  that  these  be  alternated  with  insuffla- 
tions of  four  or  five  grains  of  tannin.  Alum  mixed  with  honey 
and  the  glycerine  of  tannin  have  also  been  applied  with  a 
camel's  hair  pencil.  Alum  in  solution  in  water  or  in  vinegar 
and  water  has  been  beneficially  employed  by  gargling  and 
irrigation,  and  tannin  in  a  five  per  cent,  watery  solution  as 
spray. 

The  liquor  ferri  subsulphatis  (MonseFs  solution)  has  been 

found  by  many  to  be  an  especially  valuable  local  astringent. 

It  may  be  applied  either  pure  or  diluted  with  an  equal  part  of 

water  or  glycerine  by  means  of  a  camel's  hair  pencil  or  a  fine 

soft  swab  to  easily  accessible  diphtheritic  patches  once  or 

twice  daily.     Its  effects  are  thus  graphically  described  by  Dr. 

C.  C.  P.  Clark,1  who  has  for  twenty  years  used  no  other  local 

application :   The  salt  is  in  no  way  a  caustic,  nor,  so  far  as  he 

'New  York  Med.  Journ.,  June  7,  1884. 
11 


162  DIPHTHERIA;     ITS  NATURE   AND   TREATMENT. 

knows,  a  poison  to  "bacilli,  "  but  it  is  a  mighty  astringent,  and 
seems  to  operate  by  puckering  the  life  out  of  the  diphtheritic 
deposit  and  sucking  or  squeezing  the  bad  juice  out  of  the  living 
parts  adjacent.  The  patch  or  patches  may  indeed  reappear 
again  and  again,  but  always  with  less  density  and  diminished 
rankness  of  look."' 

Dr.  J.  Solis-Cohen x  has  found  chloride  of  iron  applied  locally 
by  firm  and  gentle  pressure  with  a  brush,  or,  preferably,  cot- 
ton-wad— the  most  serviceable  agent  he  has  used  in  topical 
treatment.  "The  drug  has  an  astringent  and  antiseptic 
action,  assists  the  detachment  of  false  membrane,  and  appar- 
ently prevents  the  spread  of  the  infection." 

From  the  occasional  topical  use  of  both  of  the  drugs  last 
referred  to,  either  pure  or  diluted  with  half  the  quantity  of 
glycerine,  I  can  testify  to  their  favorable  action  in  suitable 
cases. 

Agents  for  the  Destruction  of  False  Membrane. 

False  membrane  may  be  removed  by  the  use  of  escharotics 
(which  has  already  been  spoken  of),  by  avulsion  and  by  sol- 
vents. From  considerations  which  have  been  already  referred 
to  as  to  the  evil  of  harsh  and  irritating  measures  in  the  treat- 
ment of  diphtheria,  it  is  now  a  well-recognized  principle  that 
as  a  general  rule  the  forcible  removal  of  diphtheritic  mem- 
brane is  a  procedure  which  is  to  be  mentioned  only  to  be  con- 
demned. When  a  portion  of  a  membranous  patch  has  become 
detached  and  loosened,  while  a  deeper  portion  still  continues 
adherent,  there  is  great  temptation  to  the  inexperienced  physi- 
cian to  hasten  the  cure  by  its  removal.  But  not  only  should 
this  temptation  be  resisted,  but  especial  gentleness  in  the  giv- 
ing of  food  and  medicines  should  then  be  practiced,  since  its 
premature  detachment  is  very  liable  to  be  followed  by  an 
intensification  of  the  inflammation,  increased  absorption  of 
poison  and  a  new  formation  of  membrane. 
1  Medical  News,  June  23,  1888. 


TREATMENT.  163 

Loosened  portions  of  still  adherent  membranous  patches 
may,  when  accessible,  be  advantageously  trimmed  away  with 
scissors. 

The  removal  of  membrane  by  scraping,  rubbing  or  picking 
it  away  with  forceps  has  been  employed  by  some  in  the  early 
stage  of  the  disease  as  a  preliminary  to  the  local  application 
of  an  antiseptic,  as  will  subsequently  be  more  particularly  re- 
ferred to.  The  capabilities  and  limitations  of  such  methods 
are  so  nearly  identical  with  those  of  the  use  of  caustics  that 
they  need  not  be  further  referred  to. 

Solvents  of  False  Membrane. 

Warm  vapor  has  long  been  much  employed  for  softening, 
disintegrating  and  promoting  the  detachment  of  false  mem- 
brane. Dr.  M.  J.  Oertel,1  advocates  the  general  use  of  this 
agent  in  the  treatment  of  diphtheria,  and  that  the  inhalations 
be  practiced  as  often  and  as  long  as  possible — for  fifteen  min- 
utes every  half-hour  on  the  first  and  second  day,  allowing  only 
three  or  four  hours  for  sleep. 

The  softening  and  loosening  of  the  false  membrane  is 
effected  not  merely  by  the  action  of  the  vapor  upon  it,  but 
also  by  the  increased  secretion  of  mucus  and  the  promotion  of 
suppuration  beneath  it. 

There  can  be  no  doubt  of  the  tendency  of  warm  vapor  to  pro- 
duce all  of  these  effects,  and  that  it  is  a  valuable  therapeuti- 
cal agent  whenever  the  false  membrane  lies  loosely  and  super- 
ficially upon  the  mucous  membrane,  as  it  usually  does  in  the 
larynx,  the  trachea  and  the  bronchial  tubes.  In  the  pharynx, 
where  the  false  membrane  is  commonly  more  deeply  imbedded 
and  more  firmly  attached,  the  employment  of  this  mode  of 
treatment  is  open  to  serious  objections.  Then  the  time  re- 
quired for  the  softening  and  loosening  effect  of  the  steam  is 
necessarily  much  greater,  and  meanwhile  not  only  is  the  false 
membrane  softened,  but  the  healthy  tissue  also  is  macerated 
1  Ziemssen's  Cyclopaedia,  vol.  i. 


164  diphtheria;   its  nature  and  treatment. 

and  relaxed — a  condition  which,  while  it  promotes  suppura- 
tion, prohably  favors  also  the  penetration  of  pathogenic  fungi 
and  the  absorption  of  septic  poison.  The  tendency  of  the  use 
of  steam  to  produce  this  effect  was  pointed  out  by  Dr.  A. 
Jacobi  in  1874.  Its  actual  observation  in  a  number  of  cases 
has  long  ago  led  me  to  regard  the  valuable  application  of  this 
therapeutical  method  as  mainly  limited  to  the  treatment  of 
croup. 

The  effect  of  steam  upon  false  membranes  may  be  increased 
by  making  it  the  vehicle  of  other  soh'ents.  This  is  often  done 
by  slaking  lime  in  the  croup-kettle  or  other  receptacle,  or  by 
placing  lime-water  or  other  solvent  solution  in  the  cup  of  the 
steam-atomizer.  It  should  be  remembered  that  the  vapor 
produced  by  boiling  lime-water  is  simply — steam. 

Medicinal  agents  which  are  capable  of  dissolving  false 
membrane  without  exerting  any  injurious  effect  upon  the  liv- 
ing tissues  have  long  been  eagerly  sought  for,  and  some  of 
them  hold  an  important  place  in  the  therapeutics  of  diphtheria. 

The  principal  substances  which  have  been  thus  employed 
are  lactic  acid,  lime-water  and  other  alkalies,  pepsin,  trypsin 
and  papayotin. 

The  inferiority  in  solvent  power  of  lactic  acid  to  lime-water 
or  trypsin  has  been  shown  in  the  following  experiment  by  Dr. 
F.  E.  Waxham.2  Three  similar  pieces  of  false  membrane 
were  sprayed  at  half -hour  intervals,  one  with  a  solution  of 
trypsin,  the  second  with  officinal  lime-water,  the  third  with  a 
ten  per  cent,  solution  of  lactic  acid.  The  first  was  dissolved  in 
two  hours;  the  second,  in  three  hours;  the  third  was  softened, 
but  not  completely  disintegrated,  in  three  and  one  half  hours. 

In  rapidity  of  action  as  a  solvent  of  membrane,  lime-water 
is  probably  inferior  to  trypsin.  This  inferiority  is  illustrated 
in  the  following  experiment  by  Dr.  H.  D.  Chapin : 3  Two  pieces 

1  The  American  Journal  of  Obstetrics,  February,  1875. 

2  Chicago  Med.  Journ.  and  Examiner,  June,  1885. 

3  New  York  Med.  Record,  March  7,  1885,  p.  257. 


TREATMENT.  165 

of  very  thick  firm  membrane  in  situ  on  two  portions  of  the 
trachea,  which  had  been  bisected  post-mortem,  were  sprayed 
every  fifteen  minutes,  the  one  with  a  solution  of  trypsin,  the 
other  with  lime-water,  to  which  one  per  cent,  of  liquor  potassse 
had  been  added.  In  two  and  one  half  hours  the  former  was 
completely  diffluent,  except  the  under  side  of  its  thickest  por- 
tion, which  retained  some  membranous  structure;  the  latter 
was  'softened  but  its  integrity  was  preserved. 

Lime-water  in  therapeutical  use  where  rapid  solvent  effect 
is  required  is  inadequate.  It  may  be  sprayed  day  after  day 
upon  diphtheritic  membrane  in  the  throat  with  the  effect  only 
of  dissolving-  away  the  thinner  portions  and  superficially  soft- 
ening- and  thinning  the  thicker  portions.  Its  principal  utility 
as  a  solvent  in  the  case  of  thick  and  dense  membrane  there- 
fore consists  in  rendering  it  more  permeable  by  antiseptic 
agents  through  osmotic  action,  and  thus  giving  important 
aid  in  disinfection.  While  it  is  not  available  against  the  more 
severe  forms  of  laiyngeal  diphtheria,  it  is  of  great  value  in 
many  cases  in  which  the  membrane  is  not  very  thick.  In 
quite  a  number  of  such  cases  I  have  seen  it  keep  the  affection 
within  such  moderate  bounds  that  recover  has  taken  place 
without  the  necessity  of  an  operation. 

It  has  been  theoretically  urged  against  the  efficiency  of 
lime-water  spray  as  a  solvent  of  false  membrane  in  the  throat 
that  it  must  at  once  be  rendered  inert  by  the  carbonic  acid  in 
the  expired  breath.  That  this  supposition  is  erroneous  I  have 
shown  by  experiments  with  pieces  of  litmus  paper  held  in  the 
back  part  of  the  pharyx.1  The  same  fact  has  also  been  shown 
by  Dr.  J.  Lewis  Smith,2  who  found  by  experiment  that  mixing 
lime-water  with  one-fourth  its  quantity  of  carbonic-acid  water 
"  did  not  seem  to  impair  materially  the  solvent  power  of  the 
lime." 

In  estimating  the  therapeutical  value  of  lime-water  in  diph- 

1  See  New  York  Med.  Record,  1880,  xvii.,  p.  383. 
*Op.  cit.,  p.  322. 


166  DIPHTHERIA;     ITS   NATURE   AND   TREATMENT. 

theria  it  is  important  to  remember  that,  aside  from  its  solvent 
action  upon  false  membrane,  its  other  effects,  even  when  it  is 
used  continuously,  are  in  no  way  injurious,  but  are  in  every 
respect  eminently  calculated  to  be  beneficial.  It  is  a  mild  as- 
tringent, a  mild  antiseptic  (destroying-  bacterial  spores  in  ten 
days  (Koch),  a  local  sedative  and  antiphlogistic.  Its  very 
valuable  sedative  and  corrective  action  in  the  irritable  stom- 
ach is  well  known.  Hence  its  utility  is  much  more  likely  to 
be  underestimated  than  overrated.  From  much  experience  in 
its  use  I  regard  it  as  entitled  to  a  place  in  the  very  front  rank 
of  remedial  agents  in  the  treatment  of  diphtheria.  Lime- 
water  may  be  employed  by  internal  administration,  by  irriga- 
tion, and  as  spray,  either  pure  or  in  combination  with  other 
antiseptics. 

Other  alkalies,  such  as  liquor  potassse  or  bicarbonate  of 
soda,  have  been  added  to  lime-water  for  the  purpose  of  increas- 
ing its  solvent  power.  Such  addition  of  one  per  cent,  of  the 
former  is  recommended  by  Dr.  J.  Lewis  Smith;  and  bicarbon- 
ate of  soda  has  been  employed  in  solution  and  by  insufflation.1 
As  either  of  these  alkalies  is  known  to  be  slightly  irritating  to 
inflamed  mucous  membranes,  their  availability  for  very  fre- 
quent and  continued  application  must  be  inferior  to  that  of 
lime-water,  though  they  may  be  very  valuable  in  emergencies 
requiring  rapid  solvent  effect. 

Pepsin  acts  efficiently  only  in  an  acid  solution — one  con- 
taining from  one  to  two  tenths  of  one  per  cent,  of  hydrochloric 
acid  being  the  most  favorable.  The  fluids  of  the  mouth  and 
throat  are  usually  either  alkaline  or  neutral.  This  has  been 
regarded  as  an  important,  drawback  to  the  availability  of 
pepsin  as  a  solvent  of  false  membrane  in  situ,  and  it  has  of 
late  been  to  a  great  extent  superseded  in  general  use  for  this 
purpose  by  trypsin  and  papayotin. 

In  a  paper  recently  read  before  the  Section  on  Paediatrics 

1  Dr.  E.  M.  Moore,  Transactions  of  the  N.  T.  State  Medical  Associa- 
tion, 1885. 


TREATMENT.  167 

of  the  New  York  Academy  of  Medicine *  Prof.  R.  H.  Chitten- 
den made  the  following-  important  statements :  Even  making- 
allowance  for  the  disadvantage  just  referred  to,  pepsin  must 
at  present  he  regarded  as  a  more  reliable  solvent  of  false 
membrane  than  trypsin — not  that  trypsin  is  a  less  efficient 
solvent,  hut  that,  owing  to  the  great  difficulty  of  isolating-  it, 
no  trypsin  has  yet  heen  produced  which  is  nearly  as  powerful 
as  the  best  pepsins  which  are  now  in  the  market,  though  the 
trypsin  produced  hy  Fairchild  has  considerable  efficiency. 
The  difficulty  arising  from  the  alkalinity  of  the  fluids  in  the 
mouth  and  throat  may  be  obviated  in  the  following  man- 
ner: The  amount  of  hydrochloric  acid  in  the  pepsin  solution 
should  he  a  little  in  excess  of  that  required  for  normal  diges- 
tion— say  ahout  four  tenths  of  one  per  cent.,  in  order  to 
allow  for  its  neutralization  and  dilution.  The  solution  em- 
ployed should  he  a  concentrated  one,  and  the  applications 
should  be  very  frequent.  A  suitable  mode  of  employing  it 
would  therefore  he  by  the  following  formula : 

^     Scale  pepsin,        ....  3j —  3  ss. 

Acidi  hydrochlorici,    .         .        .  TTiij. 

Glycerini,     .        .        .  .  3  j 

Aquse  dest.,  ....  3  vij. 

M. 
To  he  applied  every  five,  ten,  or  fifteen  minutes  hy  brush  or 
atomizer. 

There  is  abundant  testimony  to  the  quite  rapid  solvent 
action  of  trypsin  upon  diphtheritic  membrane.  Dr.  H.  D. 
Chapin2  describes  a  case  in  which  extreme  symptoms  of 
tracheo-bronchial  diphtheria  which  gradually  supervened  after 
tracheotomy  were  mitigated  within  half  an  hour  and  entirely 
dispelled  in  a  few  hours  as  the  result  of  frequent  spraying 
through  the  cannula  with  a  solution  of  trypsin.  The  child  hav- 
ing died  of  blood-poisoning,  the  autopsy  showed  thick  mem- 
brane lining  the  larynx  and  trachea  down  to  the  spot  that  was 
'Medical  News,  1889,  vol.  liv.,  p.  173.  2Loc.  cit 


168  diphtheria;  its  nature  and  treatment. 

first  readied  by  the  spray;  but  below  that  point  there  were 
on'the  intensely  injected  mucous  membrane  only  disintegrated 
shreds  of  false  membrane,  which  condition  continued  as  far 
as  to  the  bronchial  tubes  of  the  second  order. 

Since  the  first  effect  of  the  application  of  a  pepsin-acid 
solution  is  to  cause  the  swelling-  up  of  false  membrane,  while 
trypsin  produces  its  direct  disintegration,  the  latter  should  be 
preferred  for  spraying  into  the  larynx  in  diphtheritic  croup. 

Trypsin  acts  best  in  an  alkaline  medium,  and  its  solvent 
action  is  undoubtedly  aided  by  that  of  the  alkali.  The  follow- 
ing is  a  suitable  mixture,  which  should  be  freshly  prepared 
when  it  is  to  be  used: 

t>     Trypsin, 3  ss. 

Sodas  bicarbonatis,       .        .        .        .         gr.  x. 

Glycerini,  3  ss. 

Aquas  destillatae,  .        .        .        .  ad  3  j. 

To  make  a  smooth  mixture  the  trypsin  should  be  rubbed 
down  with  the  water  added  little  by  little.  When  it  is  used 
with  a  brush  a  little  should  be  poured  out  in  a  saucer  for  the 
purpose,  in  order  to  avoid  returning  the  brush  into  the  solu- 
tion after  using  it.  "When  it  is  used  in  spray  the  best  method 
is  to  fit  the  atomizing  instrument  to  a  small  narrow  bottle  or 
a  test-tube,  into  which  a  drachm  or  two  of  the  mixture  may 
be  poured.  This  may  now  be  immersed  in  a  glass  of  hot  water 
until  its  contents  are  warm,  and  then  the  spray  may  be  ap- 
plied. Trypsin  acts  more  rapidly  when  at  a  temperature 
slightly  above  that  of  the  body.  The  remainder  of  the  mixt- 
ure should  be  kept  in  a  well-stopped  bottle.  These  directions 
accompany  the  trypsin  of  Fairchild,  which  has  been  referred 
to  as  being  especially  efficient.  Trypsin  should  be  applied 
very  frequently — every  ten  or  fifteen  minutes  being  not  too 
often. 

Papayotin  is  efficient  in  an  alkaline  or  a  neutral  medium, 
and  less  so  when  the  reaction  is  acid. 

Neither  of  the  solvents  last  referred  to  has  any  specific 


TREATMENT.  169 

action  upon  false  membrane,  but  they   are  simply  ferments 
which  act  with  great  power  in  dissolving-  coagulated  albumen. 

Papayotin  has  usually  been  employed  in  a  five  per  cent, 
solution  in  water,  sometimes  with  the  addition  of  an  antisep- 
tic, as  a  small  proportion  of  salicylic  acid,  applied  hourly  or 
half -hourly,  by  brush,  irrigation  or  spray.  Dr.  A.  Jacobi 1  rec- 
ommends its  use  in  the  proportions,  papayotin  one  part, 
glycerine  and  water,  each  two  to  four  parts,  applied  hourly. 
Rossbach 2  says  that  in  order  to  be  most  effective  the  solution 
should  be  applied  to  the  parts  every  five  minutes,  a  few  drops 
being  placed  upon  the  tongue  or  in  the  nose.  Very  young 
children  may  be  allowed  to  suck  a  napkin  which  is  moistened 
with  a  sweetened  solution,  or  it  may  be  inhaled  after  atomiza- 
tion.  By  this  plan  the  membrane  often  becomes  dissolved  in 
two  or  three  hours.  He  believes  that  if  this  substance  is 
properly  used  it  will  obviate  the  necessity  for  tracheotomy. 
There  is  a  general  concurrence  of  testimony  in  respect  to  both 
papayotin  and  trypsin,  that  though  they  do  in  some  cases  at 
least,  especially  in  the  early  stage  of  diphtheria,  exert  a  favor- 
able and  limiting  effect  upon  its  course,  yet  they  are  not  spe- 
cifics for  the  disease,  that  they  are  without  curative  effect  upon 
its  infiltrated  form,  and  that  the  constitutional  disease  when 
once  established  may  go  on  to  a  fatal  termination  in  spite  of 
the  dissolution  of  the  false  membrane. 

There  is  also  a  general  agreement  that  both  of  these  agents 
are  innocuous  to  mucous  membranes. 

The  following  is  a  suitable  formula  for  the  use  of  papayo- 
tin : 

5     Papayotin,       .  gr.  xxv. 

Glycerini, 3  ss. 

Aquae  destillatae,    .        .•        .        .  ad  f  j. 
M. 

The  powerful  tendency  of  jaborandi  and  pilocarpine  to  in- 

1  Therapeutic  Gazette,  1886,  145. 

2Deutsches  Arch.  f.  Klin.  Med.,Bd.  XXXVI.,  H.  3  and  4. 


170  diphtheeia;   its  natuee  and  teeatmeistt. 

crease  the  secretion  of  mucous  membranes  has  led  to  their 
administration  for  the  purpose  of  thus  causing"  the  maceration 
of  diphtheritic  membranes,  and  hastening-  their  detachment. 
Its  successful  use  in  many  cases  has  been  reported  by  G. 
Guttmann J  and  others.  Lax 2  recommends  the  following  for- 
mula 

IJ     Pilocarpini  hydrochlorat.,        .        gr.  iij. 

Pepsinas,     .        .        .        .  gr.  j.. 

Aquae  dest.,        .        .        .        .        fl.  §  ij  3  iss. 

Acidi  hydrochlorici,  .        .        gtt.  ij. 

M. 
Dose,  a  small  or  large  spoonful  to  be  given  according  to 
age  and  effect. 

Since  pilocarpine  is  liable  to  cause  depression  of  the  heart's 
action,  collapse,  nausea  and  vomiting  and  albuminuria,  and 
since  the  copious  salivation  and  perspiration  which  it  produces 
are  necessarily  weakening,  its  continued  use  for  a  long  enough 
time  to  fufill  the  above-mentioned  indication  is  now  generally 
condemned  as  dangerous. 

ANTISEPTICS. 

Cleanliness. 

In  the  "  Instructions  for  Disinfection "  by  the  New  York 
Board  of  Health,  from  which  quotation  has  been  made  in  the 
preceding  chapter,  it  is  well  remarked  that  "  disinfectants  "  {i.e. 
chemical  agents)  "  should  not  be  relied  upon  to  correct  condi- 
tions due  to  dirt,  decomposition,  defective  ventilation  and 
neglect."  This  principle,  so  true  in  reference  to  the  disinfec- 
tion of  apartments,  premises,  etc.,  is  equally  applicable  to  the 
disinfection  of  the  living  body  in  the  treatment  of  diphtheria. 
The  thorough  cleansing  by  suitable  means  of  all  surfaces 
affected  by  the  disease,  or  liable  to  become  so,  in  the  mouth,  the 
throat,  the  nasal  passages  and  elsewhere,  is  of  far  greater 

Berlin.  Klin.  Wochenschr.,  1880,  No.  40,  p.  569. 
2  Journal  de  Medicine  de  Paris,  Feb.  6,  1887. 


TREATMENT.  171 

practical  importance  in  the  whole  number  of  cases  than  the 
mere  administration  of  antiseptic  drugs,  and  the  use  of  the 
latter,  though  important,  can  in  no  case  atone  for  neglect  or 
inefficiency  in  the  former. 

The  Resistance  op  the  Organism. 

Bacteria  and  their  spores,  which  invade  the  blood  and  tis- 
sues, are  attacked,  digested,  and  destroyed  by  the  cells,1  or  in 
case  of  their  overwhelming  number  and  vigor  destroy  the 
cells.  When  the  body  is  weak  or  exhausted  by  hunger  or 
fatigue  the  power  of  thus  destroying  invading  organisms  is 
proportionally  small.  From  this  fact  it  appears  that  nutritive 
and  sustaining  measures  in  the  treatment  of  infectious  diseases 
may  properly  be  regarded  as  measures  of  disinfection,  that 
the  use  of  antiseptic  drugs  which  may  be  weakening  to  the 
patient  should  be  carefully  avoided,  and  that  an  agent  which 
merely  diminishes  in  a  slight  degree  the  vital  activity  of  bac- 
teria may  turn  the  scale  in  the  conflict  between  them  and  the 
cells,  provided  that  it  is  less  poisonous  to  the  latter  than  to 
the  former. 

The  Salts  op  Mercury. 

Among  bactericidal  drugs,  the  one  which  is  efficient  in  the 
greatest  dilution  is  the  bichloride  of  mercury.  According  to 
the  experiments  of  Koch 2  it  hinders  the  development  of  an- 
thrax bacilli  (a  comparatively  resistant  organism)  in  the 
strength  of  10ooooo  in  the  nutrient  solution,  prevents  it  in  the 
strength  of  -3-3x33-3,  kills  the  spores  of  the  bacilli  in  ten  minutes 
in  the  strength  of  g0^00,  and  with  one  wetting  in  the  strength 

of  ToW 

Other  salts  of  mercury,  as  the  sulphate,  the  nitrate,  the 
cyanide  and  the  iodides  are  also  very  efficient  bactericides, 
though  in  a  somewhat  less  degree  than  the  bichloride. 

1  Metschnikoff ,  Virch.  Archiv.  vol.  xcvi.,  p.  177,  and  xcvii.,  p.  502, 
and  Fodor,  Arch.  f.  Hygiene,  Bel.  134,  p.  149. 

2  Mittheilungen  aus  dem  k.  Gresundheitsante,  vol.  i. 


172  diphtheria;  its  nature  and  treatment. 

For  prompt  and  certain  local  antiseptic  effect  corrosive 
sublimate  is  applied  in  a  solution  of  the  strength  of  from  ^  0\  0 
to  -g^-Q  by  brush,  swab  or  atomizer.  * 

In  order  that  this  effect  shall  be  produced  it  is  necessary 
that  the  bacteria  and  their  spores  be  actually  wetted  with  the 
solution  in  its  full  strength  or  nearly  so.  If  the  affected  sur- 
faces are  covered  with  profuse  and  viscid  secretions,  as  is  often 
the  case,  they  should  first  be  cleansed  by  spraying-  or  irrigation, 
and  afterwards  dried  by  touching  them  lightly  with  absorbent 
cotton. 

A  still  greater  obstacle  is  usually  presented  in  the  false 
membrane.  If  this  be  exceptionally  thin,  superficial,  and  loose 
of  texture,  the  solution  may  penetrate  to  its  under  surface 
with  no  very  great  dilution;  but  in  proportion  as  it  is  thicker 
and  denser  this  becomes  impossible. 

But  even  if  the  false  membrane  have  previously  been  re- 
moved, the  fact  remains  that  the  fungi  of  the  disease,  so  far  as 
we  have  means  of  judging,  do  not  lie  merely  on  the  surface  of 
the  mucous  membrane  or  the  denuded  tissues,  except  at  a  very 
early  stage  of  the  disease  or  in  its  more  superficial  forms,  but 
also  beneath  the  epithelial  layers  or  even  in  still  deeper 
structures. 

It  follows  from  these  considerations  that  the  eradication  of 
diphtheria  in  its  really  deeper  and  graver  forms,  except  at  a 
very  early  stage,  even  by  the  local  use  of  this  most  powerful 
of  bactericides  must  often  be  opposed  by  insuperable  obsta- 
cles, and  this  conclusion  is  confirmed  by  experience.  For  exam- 
ple, W.  W.  Cheyne1  has  employed  the  following  treatment: 
He  first  removes  as  much  of  the  membrane  as  is  possible  with 
forceps,  and  then  applies  to  the  denuded  surface  a  watery  solu- 
tion of  bichloride  (one  in  five  hundred)  with  a  brush  every  two 
hours,  especial  attention  being  directed  to  the  margin  of  the 
affected  region.  In  the  intervals  a  gargle  of  bichloride  in  the 
strength  of  one  two-thousandth  is  used.  This  treatment  has 
1  British  Medical  Journal,  March  5,  1887,  p.  504. 


TREATMENT.  173 

"  quickly  and  completely  arrested  "  the  disease  in  several  adult 
cases  which  were  "  taken  early/'  but  in  the  case  of  children 
"  the  results  are  not  so  good." 

Corrosive  sublimate  is  also  employed  in  higher  dilution — 
that  of  3oVo>  TuViT  or  Tui to~  f°r  local  antiseptic  effect  by  fre- 
quent internal  administration,  gargling,  irrigation  and  atomi- 
zation.  That  a  solution  of  one  grain  of  corrosive  sublimate  in 
the  pint  of  water  is  a  safe  and  useful  antiseptic  wash  in  many 
cases  of  diphtheria  cannot  be  doubted;  yet  even  in  that  dilu- 
tion the  effect  of  its  frequent  application  to  diphtheriticalty 
inflamed  surfaces  has  seemed  to  me  less  beneficial  and  more 
liable  to  be  irritating  than  that  of  other  substances  yet  to  be 
mentioned.  It  should  also  be  borne  in  mind  that  in  spraying 
the  throat  and  irrigating  the  nasal  passages  of  children,  even 
with  a  solution  of  this  strength,  caution  is  needed  that  a  dan- 
gerous quantity  of  the  poisonous  salt  be  not  swallowed. 

In  view  of  the  enormous  dilution  in  which  corrosive  subli- 
mate diminishes  the  vital  activity  of  bacteria,  the  idea  that  it 
may  be  introduced  into  the  circulation  in  sufficient  quanthVy, 
even  making  allowance  for  its  constant  elimination,  to  have 
some  influence  in  the  struggle  between  the  living  body  and  its 
pathogenic  invaders  is  probably  not  altogether  chimerical. 
This  view  is  favored  by  the  results  of  the  experiments  of  Cash,1 
who  found  that  the  continued  administration  of  minute  doses 
of  sublimate  to  animals  rendered  them  capable  of  resisting 
the  effects  of  the  subsequent  inoculation  of  anthrax. 

There  is  reason  to  believe  that  the  salts  of  mercury,  inter- 
nally administered,  have  a  tendency  to  oppose  the  occurrence 
of  fibrinous  exudation  in  the  air-passages,  and  to  promote  its 
detachment  when  formed.  Reports  of  the  successful  treat- 
ment of  membranous  croup  with  calomel  have  been  too  nu- 
merous in  the  medical  literature  of  this  and  other  countries  to 
be  easily  explained  by  the  theory  of  mere  coincidence.     Though 

1  Proceedings  of  the  Physiological  Society,  Dec.  12,  1885.  Journal  of 
Physiology,  vol.  vii. 


174  diphtheria;  its  nature  and  treatment. 

that  treatment,  having-  heen  found  in  many  cases  disappoint- 
ing- in  its  result  and  injurious  in  its  effects,  was  long  ago  gen- 
erally abandoned,  yet  testimony  to  its  efficacy  continues  occa- 
sionally to  appear.  Heroic  dosage  is  an  element  in  its  em- 
ployment by  some,  as  for  instance  in  the  successful  treatment 
of  three  children  suffering  from  laryngeal  diphtheria,  twenty 
grains  of  calomel  was  given  at  first,  followed  by  ten  grains 
hourly — seven  hundred  and  twenty  grains  having  been  taken 
by  a  child  twenty-eight  months  old  in  three  clays ! x 

It  is  a  relief  to  learn  that  diphtheria  has  been  successfully 
treated  by  the  use  of  two  to  five  grains  of  calomel  every  one 
to  three  hours  until  the  dejections  are  frequent  and  green, 
then  continuing  the  same  doses  at  lengthened  intervals  so  as 
to  keep  up  the  catharsis,2  and  even  by  doses  of  one  sixth  of  a 
grain  every  hour,  increased  in  the  presence  of  threatening 
laryngeal  symptoms  to  one  third  of  a  grain  every  hour,  and 
then  to  one  grain  every  two  hours  for  five  hours,  in  a  patient 
eighteen  months  old,3  and  in  thirty-six  consecutive  cases  by 
the  following  method :  The  diseased  part  is  first  wetted  with 
a  two  to  five  per  cent,  solution  of  common  salt — then  two  to 
four  tenths  of  a  grain  of  calomel  are  blown  over  it  twice  daily, 
the  throat  being  in'  the  mean  time  gargled  every  two  hours 
with  the  salt  solution.  A  portion  of  the  calomel  becomes  bi- 
chloride, and  the  remainder  passes  into  the  stomach  and  pro- 
duces free  catharsis.4 

There  is  a  concurrence  of  testimony  from  many  judicious 
practitioners  as  to  the  benefit  which  may  be  derived  from  pur- 
gative doses  of  calomel  at  the  early  stage  of  diphtheria,  es- 
pecially in  cases  in  which  there  is  high  fever  with  deficient 
secretions  and  marked  nervous  disturbance — a  benefit  which 

1  Dr.  J.  P.  Klingensmith,  of  Blairsville,  Pa.,  New  York  Medical 
Record,  July  12,  1884,  p.  36. 

2  Dr.  W.  H.  Daly,  of  Pittsburg,  New  York  Med.  Record,  June  12, 
1886,  p.  692. 

3  Dr.  Geo.  B.  Fowler,  New  York  Med.  Record,  Nov.  19,  1887,  p.  647. 
4Kotzuski,  Jahrb.  f.  Kinderh.,  xxi.,  p.  272. 


TREATMENT.  175 

I  have  observed  in  many  cases,  and  which  was  referred  to 
in  my  first  publication  (1876).  It  may  be  given  in  a  single  dose 
of  from  two  to  ten  grains,  or  in  doses  of  a  fraction  of  a  grain 
(one  tenth  to  one  half)  repeated  frequently  (from  every  twenty 
minutes  to  every  two  hours)  until  its  characteristic  purgative 
effect  is  produced. 

At  the  present  time  mercury  is  most  generally  employed 
in  the  treatment  of  diphtheria  in  the  form  of  the  bichloride. 
Its  use  in  large  doses  (one  quarter  to  one-half  grain  or  more 
daily)  has  been  advocated  in  this  country  by  Dr.  W.  Pepper,1 
(and  hence  widely  known  as  the  "Pepper  treatment")  and 
subsequently  by  Dr.  A.  Jacobi 2  and  by  many  others. 

Of  its  efficacy  in  diphtheritic  croup,  Dr.  Jacobi 3  says,  "  I 
have  never  since  1863  seen  so  many  cases  of  tracheotomy  get- 
ting well  as  between  1882  and  1886,  when  the  bichloride  was 

constantly  used  as  mentioned I  can  name  a  dozen  of 

New  York  physicians,  some  of  whom  have  often  performed 
tracheotomy,  who  can  confirm  the  above  statements  from 
their  own  observations.  Nor  does  the  opinion  of  those  differ 
who  constantly  perform  intubation.  I  know  that  O'Dwyer, 
Dillon  Brown  and  Huber  have  come  to  the  same  conclusions." 
The  doses  referred  to  by  Dr.  Jacobi  are  "from  one  sixtieth  to 
one  fortieth  of  a  grain  and  sometimes  more,"  given  hourly  in 
a  tablespoonful  of  water,  milk  or  other  compatible  fluid. 

To  the  valuable  efficacy  of  the  bichloride  of  mercury  (as, 
indeed,  of  most  other  prominent  remedies  used  in  the  treat- 
ment of  diphtheria)  there  is  in  recent  literature  a  striking 
array  of  testimony,  of  which  the  following  examples  are  given 
mainly  to  illustrate  different  modes  of  employing  it : 

Dr.  E.  C.  Carter,  Assistant  Surgeon  United  States  Army/ 

1  Transactions  of  the  American  Medical  Association,  1881. 

■  "  The  Medicinal,  mainly  Mercurial,  Treatment  of  Pseudo-Membra- 
nous Croup,"  New  York  Medical  Record,  1884,  vol.  25,  p.  573;  and  "A 
System  of  Medicine  by  American  Authors,"  Phila.,  1885,  p.  705. 

3"  Therapeutics  of  Diphtheria,"  Medical  News,  June  10,  1888,  p.  663. 

4  Medical  News,  Nov.  27,  1886,  p.  593. 


176  DIPHTHERIA;    ITS    NATURE    AXD    TREATMENT. 

in  an  epidemic  of  diphtheria  near  Fort  Thomas,  Arizona,  hav- 
ing treated  the  first  eleven  cases  with  other  remedies  with 
four  fatal  results,  gave  bichloride  in  thirty -four  subsequent 
cases  in  doses  varying-  from  one  sixty-second  to  one  twenty- 
fourth  of  a  grain  with  unvarying  success.  That  they  were 
genuine  cases  of  diphtheria  seems  to  be  attested  by  the  fact 
stated  that  twelve  of  the  patients  who  recovered  had  paraly- 
sis. 

Dr.  P.  Werner,1  having  previously  lost  between  sixty  and 
seventy  per  cent,  of  ninety  cases,  employed  bichloride  treat- 
ment in  the  succeeding  seventeen — mostly  severe  ones — with 
only  two  fatal  results,  and  those  in  cases  seen  only  a  few 
hours  before  death.  He  gave  doses  of  2x0  to  ^  of  a  grain  (ac- 
cording to  age),  well  diluted  in  water,  every  twenty  or  thirty 
minutes  while  the  patients  were  awake,  so  that  one  quarter 
of  a  grain  was  taken  daily  by  young  children,  one  half  by 
older  ones,  and  three  quarters  by  adults. 

J.  Stumpf,2  having  in  the  early  part  of  an  epidemic  lost 
twenty-two  out  of  twenty-nine  cases,  employed  in  the  succeed- 
ing thirty-one  cases  the  bichloride  of  mercmy  only,  with  fav- 
orable result  in  all  but  two.  He  administered  in  spray  one 
fluid  drachm  of  a  solution  of  the  strength  of  -^-q,  yqqq  or  toW 
(according  to  age)  hourly  for  five  times,  then  every  two  hours 
for  five  times,  and  subsequently  every  three  hours. 

Dr.  E.  L.  Oatman,3  of  ISTyack,  N.  Y.,  having  previously  lost 
ten  out  of  twenty-three  cases  under  treatment  with  iron  in 
large  doses  and  free  stimulation,  has,  since  the  addition  of 
local  treatment  with  the  bichloride,  lost  only  one  out  of  thirty- 
four  cases.  Dr.  Oatman  prepares  a  number  of  swabs  by 
firmly  twisting  absorbent  cotton  around  the  end  of  a  small 
stick.  Every  hour  one  of  these  is  dipped  into  a  solution  of  the 
bichloride  (two  grains  to  the  pint)  and  passed  into  the  throat 

'St,  Petersburg  Med.  Wochenschr.,  1886,  r.  F.  III.,  p.  81. 
2Muenchener  Med.  Wochenschr.,  1887,  p.  219. 
3  New  York  Med.  Record,  April  23,  1887,  p.  465. 


TREATMENT.  177 

until  it  touches  the  posterior  wall  of  the  pharynx  and  then  in- 
stantly withdrawn  and  burnt,  no  swab  being-  used  a  second 
time.  More  or  less  of  the  membrane  always  adheres  to  the 
swab.  This  procedure  is  repeated  hourly  until  the  disease  be- 
gins to  subside,  which  it  usually  does  in  forty-eight  hours.  If 
the  nares  are  affected,  the  nose  is  syringed. 

The  biniodide  of  mercury  is  regarded  as  especially  effica- 
cious by  some.  It  is  employed  by  Dr.  C.  G.  Rothe,1  of  Alten- 
burg,  in  the  following  formula : 

r>     Hydrargyri  biniodidi,       .        .  gr.  £. 

Potassii  iodidi,  ....  gr.  iij — gr.  ivss. 

Aquae  destillatas,      .        .        .  fl.  3  j  3  vij. 

Tincturae  aconiti,      ...        .  th,  xv. 
M. 

A  teaspoonful  is  given  hourly  to  a  child  under  three  years 
of  age.     Dr.  Rothe  has  thus  treated  successfully  forty  cases. 

Extraordinarily  favorable  results  from  the  use  of  the  cya- 
nide of  mercury  are  reported  by  Dr.  J.  Bree 2  and  by  Dr.  H. 
Sellden,3  a  Swedish  provincial  medical  officer.  The  latter  re- 
ports fourteen  hundred  cases  treated  by  himself  and  his  col- 
leagues, with  a  total  mortality  of  sixty-nine,  or  4.9  per  cent. 
The  formula  he  recommends  is  as  follows :  Cyanide  of  mercury, 
two  centigrammes  (gr.  ^) ;  tincture  of  aconite,  two  grammes 
(Til  xxx.);  honey,  fifty  grammes  (f  j.  3  ivss.);  distilled  water 
one  hundred  and  fifty  grammes  (  §  iv.  3  vss.).  Mix  and  give  a 
teaspoonful  every  fifteen,  thirty  or  sixty  minutes,  according  to 
the  patient's  age.  A  gargle  of  the  cyanide  in  peppermint 
water  in  the  strength  of  To,Voo  is  also  to  be  used  frequently. 

Inunction  of  mercurial  ointment  has  also  been  much  em- 
ployed in  the  treatment  of  diphtheria.     For  its  more  rapid 


1  Journ.  de  MM.,  June  5,  1887. 

2 "  Behandlung  der  Diphtherie  mit  Quecksilbercyan,"  Dissertation, 
Berlin,  1886. 

3  London  Lancet,  March  24,  1888,  p.  591. 
12 


178  DIPHTHEKIA  ;  .  ITS  JSTATUKE   AND   TKEATMENT. 

absorption  the  oleate  is  recommended  by  Dr.  A.  Jacobi  *  — ten 
or  twelve  drops  to  be  rubbed  into  the  skin  every  hour  or  two. 
The  hypodermic  injection  of  corrosive  sublimate  is  recom- 
mended by  the  same  author — four  or  five  drops  of  a  one-half 
or  one  per  cent,  solution  to  be  so  used  from  four  to  six  times  a 
day  or  more.  Dr.  F.  P.  Henry 2  states  that  the  hypodermatic 
injection  of  corrosive  sublimate  is  so  painful  that  few  will  con- 
sent to  its  repetition,  and  prefers  the  bicyanide  of  mercury, 
since  it  is  compatible  with  cocaine,  which  the  former  is  not. 
He  has  found  its  employment  in  many  cases  by  the  following 
formula  comparatively  painless : 

5     Hydrarg.  bicyanid.,    ....    gr.  ij. 
Cocain.  hydrochlorat.,        .        .        .    gr.  iv. 

Aquas  destillat., fl.  §  ss. 

M. 
Fifteen  minims  to  be  injected  beneath  the  skin  in  the  case 
of  an  adult. 

Mercury  by  fumigation  has  been  used  in  the  treatment  of 
diphtheritic  croup  with  remarkable  success  by  Dr.  J.  Corbin,3 
of  Brooklyn.  The  child  is  placed  in  a  crib  under  a  tent  pre- 
pared with  barrel-hoops  and  blankets.  Calomel  is  volatilized 
in  the  tent  by  heat,  from  forty  to  sixty  grains  being  used  in 
the  case  of  a  child  eight  or  ten  years  of  age.  The  lamp  should 
be  powerful  enough  to  volatilize  a  drachm  of  calomel  in  one 
minute  in  order  to  avoid  overheating  the  air  in  the  tent.  The 
child  is  kept  under  the  canopy  for  twenty  minutes,  when  the 
blanket  is  removed.  This  is  repeated  every  two  or  three 
hours  during  the  first  day.  After  that  period  the  cough  is 
usually  loosened,  and  the  intervals  between  the  fumigations 
are  lengthened,  but  they  should  be  at  once  resumed  if  the 
cough  tightens.     In  some  cases  two  or  three  fumigations  daily 

JA  System  of  Practical  Medicine  by  American  Authors,  vol.  i.,  p. 
705. 

2  Medical  News,  Nov.  3,  1888. 

3  New  York  Medical  Journal,  March  10,  1888,  p.  261. 


TREATMENT.  179 

have  been  continued  for  over  a  week.  The  aphonia  may  not 
disappear  for  a  week  or  more,  but  that  need  excite  no  alarm. 
This  treatment  is  not  a  substitute  for  tracheotomy  or  intuba- 
tion. 

Including-  sixteen  cases  thus  treated  by  himself,  and  four- 
teen by  three  other  physicians,  Dr.  Corbin  reports  thirty 
cases,  of  which  twent3^-five,  or  about  84  per  cent.,  recovered. 
In  one  of  the  fatal  cases  the  treatment  was  abandoned  by  the 
family.  In  none  of  the  other  four  did  death  result  from  ob- 
struction of  respiration,  but  from  the  effects  of  toxasmia. 

The  valuable  action  of  mercury  in  the  treatment  of  diph- 
theria, like  that  of  most  other  remedies,  is  greatest  when  it  is 
employed  at  an  early  stage  of  the  disease.  Then  it  has  a  ten- 
dency (in  some  cases  at  least)  to  limit  the  extension  and  mod- 
erate the  intensity  of  the  affection,  and  thus  to  diminish  the 
subsequent  constitutional  poisoning.  But  when  the  septic 
condition  is  once  established  it  has  not  the  power  to  arrest  it, 
but  if  excessively  or  too  long  used  is  very  liable  to  aggra- 
vate it. 

In  the  internal  administration  of  the  salts  of  mercury  it  is 
most  important  to  remember  that  these  valuable  therapeuti- 
cal agents,  when  used  beyond  certain  limits  as  to  frequency, 
quantity  and  continuance,  are  dangerous  irritant  and  depress- 
ing poisons;  that  this  action  of  them  must  be  especially  dele- 
terious in  a  disease  which  is  in  itself  so  depressing  as  diph- 
theria, and  is  particularly  liable  to  be  overlooked  from  being- 
attributed  to  the  disease. 

In  a  judicious  and  timely  protest  against  the  abuse  of  mer- 
curials in  the  treatment  of  diphtheria,  Dr.  J.  E.  Winters1 
says,  "  I  know  that  as  the  result  of  the  inconsiderate  use  of 
mercurials  in  the  treatment  of  diphtheria,  physicians  are  often 
called  upon  to  treat  the  consequences  of  their  want  of  cau- 
tion ;  while  they  have  blindly  ascribed  the  rapidly  progressive 


^'Diphtheria  and  its   Management,"  New  York  Medical  Record, 
Dec.  5,  1885,  p.  617. 


180  DIPHTHERIA;    ITS   NATURE    AND   TREATMENT. 

anasmia,  prostration,   marasmus   and    death   to  the  disease 
alone.  .  .  . 

"I  have  unequivocal  and  direct  evidence  of  the  injurious 
effects  of  bichloride  of  mercury  from  two  intelligent  physicians 
who  have  had  diphtheria,  and  who  both  experienced  the  de- 
pressing- effect  of  the  drug-.  They  told  me  that  they  felt  de- 
pressed as  soon  as  the  mercurial  began  to  have  an  appreciable 
action  on  the  intestinal  tract,  and* that  there  was  a  feeling-  of 
nausea  and  sinking  even  preceding  this.  I  may  add  that  after 
the  discontinuance  of  the  bichloride  both  patients  felt  within 
three  hours  the  strengthening  effect  of  the  tincture  of  iron  in 
full  doses  given  hourly/' 

Carbolic  Acid. 

Carbolic  acid  is  a  far  less  powerful  bactericide  than  corro- 
sive sublimate.  An  aqueous  solution  of  it  in  a  strength  of 
y-gVo  hinders  the  growth  of  anthrax  bacilli:  -^  prevents  it; 
y^j-  to  4-J~o  prevents  the  growth  of  other  bacteria;  a  five  per 
cent,  solution  requires  more  than  twenty -four  hours  to  kill  the 
spores  of  anthrax  bacilli,  though  a  one  per  cent,  solution  de- 
stroys the  bacilli  themselves  in  ten  minutes.  Its  use  in  full 
strength  or  with  slight  dilution  as  a  caustic  has  already  been 
referred  to  (page  158). 

Carbolic  acid  has  great  utility  in  the  local  treatment  of 
diphtheria,  since  in  suitable  dilution  it  is  not  only  an  efficient 
antiseptic  but  also  has  a  valuable  sedative  and  antiphlogistic 
action.  Dr.  T.  M.  Pruclden  1  has  shown  that  a  solution  of  car- 
bolic acid  of  the  strength  of  t^t,  locally  applied  under  condi- 
tions in  which  inflammatory  changes  commonly  occur,  modi- 
fies those  changes  by  preventing  any  considerable  emigration 
or  locomotion  of  white  blood-cells. 

Salicylic  Acid. 
Salicylic   acid   is   an   efficient    antiseptic.     It  hinders  the 
growth  of  bacteria  in  a  solution  of  the  strength  of  ■s-^wo>   Pre~ 
'American  Journal  of  the  Medical  Sciences,  Jan.,  1881,  p.  82. 


TREATMENT.  181 

vents  it  in  that  of  Y^Vnrj  and  kills  bacteria  in  that  of  FV  Suc- 
cessful results  have  been  claimed  from  its  use  in  powder  by 
insufflation  and  by  brushing-  it  over  the  parts  affected.1  The 
following  formula  for  its  use  is  recommended  by  M.  Ory :  • 

1^     Acidi  salicylici,  .  .        .  gr.  v. 

Glycerini, fl.  3  iij. 

Aquas  lauro-cerasi,  .  tt[  xvi. 

Inf  us.  eucalypti,        .        .        .        .  fl.  3  iijss. 
M. 

To  be  applied  by  brush  every  hour  by  day  and  every  two 
or  three  hours  at  night.  It  is  said  to  hasten  the  disappearance 
of  false  membrane. 

Salicylic  acid  is  more  irritating  to  inflamed  surfaces  than 
carbolic  acid.  According  to  the  statistics  of  Schiiler,3  in  41 
cases  treated  with  chlorate  of  potassium  there  were  6  deaths; 
in  23  cases  treated  with  carbolic  acid  there  was  1  death;  in 
15  cases  treated  with  salicylic  acid  there  were  7  deaths. 

Dr.  A.  d'Espine 4  has  ascertained  by  experiments  that  sali- 
cylic acid,  even  in  a  solution  of  1 :  2000,  is  an  excellent  parasiti- 
cide of  the  bacillus  of  diphtheria.  Its  harmlessness  in  this 
dilution  makes  it  a  very  available  application  by  irrigations, 
which  should  be  repeated  hourly.  The  especial  utility  of  this 
employment  of  it  would  obviously  be  in  the  early  stage  of  the 
disease  and  as  a  prophylactic. 

Crinoline. 

Chinoline  is  a  powerful  antiseptic,, and  in  strong  concen- 
trations is  sharply  caustic.  Its  local  effect  in  the  treatment 
of  diphtheria  has  been  favorably  reported  upon  by  Dr.  O. 

1  Noeldechen  of  Pforta,  Deutsche  Med.  Zeitung,  Nos.  33-36,  1886. 

2  Revue  Gen.  de  Clinique  et  de  Therapeutique,  July  5,  1888. 

3  Berlin  Klin.  Woch.,  40. 

4  Medical  News,  1889,  54,  p.  187,  from  Revue  M6dicale  de  la  Suisse 
Romande,  Jan.  20,  1889. 


182  diphtheria;  its  nature  and  treatment. 

Seifert1  and  others.  Dr.  Seifert  used  it  in  a  five  per  cent, 
solution  in  equal  parts  of  alcohol  and  water  applied  by  brush- 
ing- from  twice  daily  to  every  three  hours,  and  as  a  gurgle  in 
the  following'  solution:  chinoline  1.0  (15  grains);  water,  500 
(1  pint);  alcohol  50.  (1|  ounces);  oil  of  peppermint,  two  drops. 
Prof.  Ahlfeld,2  however,  in  one  hundred  and  ten  cases  of  chil- 
dren treated  by  this  method,  reported  a  mortalitj7  of  28  per 
cent.,  and  Dr.  Lunin  under  similar  treatment  lost  fifteen  of 
twenty-eight  patients. 

Resorcine. 

Resorcine  is  also  a  powerful  antiseptic,  and  is  less  caustic 
than  carbolic  acid.  It  has  been  employed  by  Liblond 3  in  solu- 
tion in  glycerine  (one  in  ten  to  fifteen  parts)  applied  locally 
every  two  hours  with  favorable  results,  and  like  results  from 
a  similar  use  of  it  have  been  reported  by  Fraigniaud,4  and  H. 
Callias.5  The  latter  employed  a  five  to  ten  per  cent,  solution 
in  water  with  a  little  glycerine  by  pencilling  hourly,  and  a 
two  per  cent,  solution  every  two  hours  by  spraying.  On  the 
other  hand  Dr.  Lunin  lost  nineteen  of  twenty-nine  patients 
treated  with  resorcine. 

Sulphur. 

Sulphur  has  long  been  much  employed  in  the  treatment  of 
diphtheria,  mainly  by  insufflation,  and  its  effects  have  been 
lauded  by  many.  When  thus  used  a  portion  of  it  is  changed 
into  sulphurous  acid  or  sulphuretted  hydrogen,  both  of  which 
are  powerful  bactericides.  Insufflation  is  a  difficult  procedure 
in  the  cases  of  young  ^children,  and  the  remedy  itself  is  un- 
pleasant. Dr.  H.  V.  Knaggs,  of  London,6  recommends  the  fol- 
lowing preparation  as  palatable  and  readily  taken  by  children  : 

1  Jahrb.  f.  Kinderh.,  1884,  p.  462. 
2Jahrb.  f.  Kinderh.,  1884,  p.  463. 

3  Journ.  de  MeU  de  Paris,  Dec.  20,  1884. 

4  Union  M6dicale,  1885,  p.  493. 

5  Quoted  by  Le  Gendre,  Archiv.  de  Laryngol.,  No.  1,  1887. 
B  Therapeutic  Gazette,  March  15,  1888,  p.  153. 


TREATMENT.  183 

fy     Precipitated  sulphur  (pure),          .        .     3  jss. 
Chocolate  powder,          .        .        .        .    3  j. 
Cinnamon-water  (concentrated,  1  in  40),  fl.  3  j. 
Grycerine, fl.  1  iij- 

Mix  the  powders  in  a  mortar;  then  gradually  add  the  glyc- 
erine with  constant  trituration,  and  lastly  the  cinnamon- 
water.  Dose,  half  a  teaspoonful  to  a  teaspoonful  every  hour 
or  oftener.  Dr.  Knaggs  reports  the  treatment  of  seventy-five 
cases  of  diphtheria  by  this  drug-  alone,  with  no  fatal  result. 

Rapid  disappearance  of  membrane  and  corresponding  gen- 
eral improvement  are  said  to  have  followed  the  use  of  sulphur- 
ous acid  in  teaspoonful  doses  every  half-hour  to  every  two 
hours  according  to  the  gravity  of  the  case.1 

Hyposulphite  of  soda  has  been  used  during  the  past  year 
by  Dr.  J.  H.  Fruitnight,2  of  this  city,  in  connection  with  iron 
and  other  appropriate  treatment  in  thirty  cases  with  success- 
ful result  in  all  but  two.  The  remedy  has  been  used  in  the 
strength  of  3  j  —  3  jss —  3  ij  (according  to  the  age  of  the  patient) 
in  two  fluid-ounces  of  water,  and  of  this  a  teaspoonful  has 
been  given  every  two  hours.  In  a  few  of  the  cases  the  solu- 
tion has  been  applied  with  a  brush  or  with  the  atomizer,  the 
gentlest  possible  mode  of  application  being  always  preferred. 

Chlorine,  Bromine,  and  Iodine. 

Free  chlorine,  bromine,  and  iodine  are  among  the  most 
powerful  bactericides.  Chlorine  kills  bacteria  in  a  watery 
solution  of  the  strength  of  -^foo" 5  bromine  in  that  of  -^V  o>  an(^ 
iodine  in  that  of  15100.  In  internal  use  their  germicidal  effect 
is  greatly  diminished  by  their  conversion  in  vital  fluids  which 
contain  alkalies  (as,  for  example,  blood-serum)  into  chlorides, 
bromides  and  iodides.  Their  principal  utility  as  antiseptics 
in  the  treatment  of  diphtheria  is  therefore  in  their  local  effect. 

For  cleansing  and  deodorizing  a  foul  diphtheritic  throat, 

1  Dr.  H.  L.  Snow,  British  Medical  Journal,  Oct.  8,  1887,  p.  773. 

2  Archives  of  Paediatrics,  October,  1888,  p. 601. 


184  DIPHTHERIA;    ITS   NATURE    AND    TREATMENT. 

solutions  of  chlorine  have  long  been  much  prized,  and  are 
among-  the  most  efficient  agents  in  our  possession.  The  best 
of  these  is  the  liquor  soda?  chloratse,  from  two  to  four  fluid- 
drachms  of  which  in  eight  fluid-ounces  of  water  may  be  applied 
every  hour  or  two  by  gargling,  irrigation  or  atomization. 

There  has  been  much  testimony  to  the  successful  employ- 
ment of  bromine  in  the  treatment  of  diphtheria ;  but  this  ex- 
perience of  its  utility  has  been  by  no  means  universal.  Like 
many  other  powerful  antiseptics  it  may  doubtless  be  in  skillful 
hands  an  effective  therapeutical  weapon  against  diphtheria; 
but  its  use  in  full  strength  or  slight  dilution  is  opposed  by  the 
considerations  which  have  been  referred  to  in  regard  to  cor- 
rosive and  irritating  applications  generally,  and  in  high  dilu- 
tions it  has  not  been  shown  to  have  greater  curative  efficacy 
than  other  less  disagreeable  remedies.  It  is  recommended  by 
Dr.  Hiller *  in  the  following  combination : 
3     Potassii  bromidi, 

Bromi, aa    gr.  iv. 

Aquas  dest., I  vj.  3  ij. 

M. 
To  be  applied  by  brush  to  the  pharynx  every  two  or  three 
hours  and  also  used  by  inhalation. 

Dr.  P.  Hesse,2  from  his  experience  with  one  hundred  and 
fifty  cases,  regards  bromine  as  the  most  valuable  local  appli- 
cation in  diphtheria.  He  used  a  solution  of  five  decigrammes 
(gr.  |)  each  of  bromine  and  bromide  of  potassium  in  two  hun- 
dred grammes  (  ?  vj.  3  ij.)  of  water  applied  locally  every  two 
or  three  hours  and  also  dropped  on  the  sponge  of  an  inhaler 
and  so  used  for  five  minutes  every  half-hour.  Latterly  he 
used  the  solution  by  inhalation  only,  varying  its  strength 
according  to  the  severity  of  the  case. 

Dr.  W.  H.  Thomson  has  employed  bromine  successfully  in 
the  treatment  of  a  large  number  of  cases  of  diphtheria,  by  a 

1  Deutsche  Med.  Wochenschr.,  1882,  ix.,  22,  p.  328. 
2Deutsches  Archiv.  f.  Klin.  Med.,  1885-6,  xxxviii.,  p.  479. 


TREATMENT.  185 

method  of  which  the  following-  account  is  abbreviated  from  a 
fuller  statement  by  himself  which  is  contained  in  "A  Treatise 
on  Diphtheria "  by  Dr.  A.  Jacobi :  Lawrence  Smith's  solutio 
bromini  is  first  prepared  by  the  following-  method :  "  Take  two 
ounces  of  a  saturated  solution  of  bromid.  potass,  in  water;  add 
to  this,  in  a  bottle,  with  constant  shaking,  one  ounce  of  bro- 
mine. It  is  better  to  add  a  part  and  then  let  it  stand  awhile 
before  adding  the  rest.  Then  fill  up  gradually,  and  with  con- 
stant shaking,  with  water,  until  it  measures  four  ounces."  It 
should  not  be  ordered  in  a  mixture  with  either  glycerine  or 
sugar,  as  it  is  thereby  decomposed.  If  not  exposed  to  too 
strong'  a  light  it  keeps  for  several  days. 

Locally  this  solution,  mixed  with  an  equal  part  of  glycerine, 
or,  in  some  cases,  in  full  strength,  is  applied  to  the  membrane 
with  a  hair-pencil  as  gently  as  possible.  If  the  membrane  is 
very  extensive  and  the  parts  much  swollen  or  difficult  to  reach, 
one  half  a  drachm  to  one  drachm  of  the  solution  to  the  pint  of 
warm  water  is  applied  by  douching  with  a  Davidson's  S3^ringe. 

Internally  from  six  to  twelve  drops  of  Smith's  solution  in  a 
tablespoonful  of  sweetened  water  is  given  every  hour,  two,  or 
three  hours,  according  to  the  urgency  of  the  case,  and  contin- 
uously, no  other  medicine  being  taken  until  the  disappearance 
of  the  membrane.  It  should  be  swallowed  promptly,  as  the 
disagreeableness  of  bromine  is  due  much  more  to  its  fumes 
than  its  taste. 

Tincture  of  iodine  has  long  been  much  employed  as  a  local 
application  in  diphtheria,  and  many  reports  attest  its  efficacy 
as  a  caustic  and  antiseptic  in  causing  the  shrivelling  and  rapid 
disappearance  of  membrane.  It  has  also  been  much  used  in 
such  combinations  as  the  following: x 
5     Tinct.  iodi., 

Tinct.  ferri  chloridi,      .        .        .      aa    fl.  3  j. 

Acidi  carbolici, gr.  x. 

Glycerini, fl.  §  ss. 

M.     Apply  by  brush  several  times  daily. 
'Dr.  Keating,  Boston  Med.  and  Su*g.  Journ.,  1885,  Jan.  22. 


186  diphtheria;  its  nature  and  treatment. 

It  has  also  been  used  internally;  as  by  Dr.  E.  Aclainson1 
who  treated  fifty-five  cases,  including-  some  very  bad  ones, 
with  doses  of  two  or  three  minims  in  syrup  aurantii  and  water 
every  two  hours  to  a  child  of  six  years  with  only  two  fatal 
results.  The  same  remarks  as  to  its  great  utility  and  its  infe- 
rior eligibility  to  some  other  drugs  in  the  treatment  of  diph- 
theria, both  in  stronger  and  weaker  solutions,  apply  to  iodine 
as  to  bromine,  though  in  a  somewhat  less  degree. 

Iodoform. 

"  It  is  now  regarded  as  an  established  fact  that  iodoform  is 
not  a  parasiticide.  ...  It  is  believed  by  some  to  have  a  de- 
structive effect  on  the  ptomaines  generated  b3T  the  bacteria 
through  the  action  of  the  free  iodine  or  iodine  compound  which 
is  liberated." 2  It  cannot  be  doubted  that  iodoform  has  a  val- 
uable antiseptic  action,  and  its  local  ansesthetic  effect  and  ten- 
dency to  diminish  secretion  render  it  valuable  in  the  treat- 
ment of  diphtheria.  It  is  important,  however,  that  its  use 
should  be  preceded  or  accompanied  by  other  disinfectant 
measures. 

It  may  be  applied  in  powder,  by  brush  or  insufflator,  pure 
or  mixed  with  half  its  weight  of  starch  or  with  three  parts  of 
sugar.  Good  results- in  preventing  the  extension  of  membrane 
down  the  trachea  after  tracheotomy,  by  the  insufflation  of 
iodoform  through  the  tube,  have  been  reported  by  George 
Shirres3  (who  thus  used  ten  to  fifteen  grains  eA~ery  four  hours 
in  two  cases)  and  others. 

The  following  solution  to  be  applied  by  pencilling  is  recom- 
mended by  Le  Gendre : 4 

Iodoform        .         .         2.50  grammes     (38  grains). 
Balsam  of  tolu      .         5  "  (75  minims). 

Ether     .        .        .25.  "        (6  ±  drachms). 

1  Practitioner,  London,  July,  1885,  p.  16. 

2  American  Journal  of  the  Medical  Sciences,  October,  1888,  p.  401. 

3  London  Lancet,  July  24,  1886,  p.  164. 
4Archiv.  de  Laryngol.,  No.  1,  1887. 


TREATMENT.  187 

Dr.  Gr.  Mundie '  prefers  the  application  of  iodoform  to  the 
throat  in  ethereal  solution  by  spraying*.  The  ether  appears 
to  constringe  the  congested  capillaries,  and  the  iodoform  is 
deposited  in  a  thick  film  on  the  surface. 

Iodoform  has  been  regarded  by  many  as  an  especially  val- 
uable agent  in  the  treatment  of  the  diphtheria  of  wounds.  Its 
successful  use  in  diphtheritic  invasion  of  the  tracheotomy 
wound  has  been  reported  by  Plenio 2  and  others  in  the  form  of 
powder,  iodoform-vaseline  or  iodoform-collodion.  It  may  be 
mixed  with  either  of  these  excipients  in  the  proportion  of  one 
to  eight. 

Iodol  has  a  similar  action  and  like  applicabilities  to  those 
of  iodoform. 

Chloral. 

Hydrate  of  Chloral,  first  recommended  in  the  local  treat- 
ment of  diphtheria  by  Dr.  Accetella,3  of  Italy,  has  since  been 
much  employed  and  highly  prized  by  many.  It  is  an  efficient 
antiseptic,  hindering  the  development  of  bacteria  in  the 
strength  of  tqVo".  It  is  also  a  powerful  irritant  to  raw  or 
especially  sensitive  surfaces.  Applied  to  the  affected  part  by 
brush  every  hour  or  two  in  the  form  of  the  officinal  syrup  of 
chloral  of  the  British  Pharmacopoeia  (ten  grains  to  the 
drachm),  it  promptly  arrests  fcetor  and  is  said  to  cause  the 
rapid  solution  and  disappearance  of  membrane. 

Dr.  A.  Mercier 4  gives  internally  the  syrup  of  chloral  of  the 
French  codex  (one  in  twenty)  in  doses  of  two,  three  or  five 
grammes  every  half-hour  or  hour,  no  drink  being  allowed  for 
some  time  afterward.  In  forty-eight  hours  after  the  treat- 
ment is  begun  the  false  membrane  has  dissolved  and  disap- 
peared, when  the  further  use  of  the  chloral  becomes  painful. 

1  London  Lancet,  June  5,  1886,  p.  1103. 

2  Jahrb.  f.  Kinderh.,  Bd.  xxii.,  H.  4. 

3  Campania  Medica,  No.  12,  1873. 

4Le  Concours  MM.,  Aug.  27,  1887,  p.  411. 


188  diphtheria;  its  nature  and  treatment. 

By  this  treatment,  Dr.  Mercier  has  saved  ninety-five  out  of 
one  hundred  cases. 

Oxygen. 

Oxygen  is  one  of  the  most  powerful  of  disinfectants  and 
antiseptics.  It  has  been  principally  employed  in  the  treat- 
ment of  diphtheria,  locally  by  means  of  the  permanganate  of 
potassium,  locally  and  internally  in  peroxide  of  hydrogen,  and 
as  convej^ed  through  the  blood  to  the  tissues  by  means  of  the 
salts  of  iron. 

From  the  readiness  with  which  it  parts  with  oxygen,  per- 
manganate of  potassium  is  a  powerful  antiseptic,  and  in  a 
solution  of  the  strength  of  from  three  to  five  grains  to  the 
ounce  of  water  is  a  most  valuable  local  application  in  the 
treatment  of  diphtheria.  Dr.  Mason 1  prepares  a  stock  solu- 
tion of  two  drachms  of  the  permanganate  in  three  ounces  of 
distilled  water,  and  uses  a  teaspoonful  of  this  solution  in  one 
ounce  and  a  half  or  two  ounces  of  water  as  spray.  It  promptly 
arrests  foetor,  which  does  not  return. 

Peroxide  of  hydrogen,  though  not  a  new  substance,  has  of 
late  been  brought  prominently  forward  as  an  especially  valu- 
able antiseptic  in  the  treatment  of  diphtheria,  and  in  the 
hands  of  some  has,  like  most  new  remedies,  produced  brilliant 
therapeutical  results.  Such  results  have  been  claimed  by 
Vogelsang 2  and  by  Hofmokl.3 

Dr.  M.  P.  Hatfield,4  of  Chicago,  has  used  it  successfully  in 
eighteen  cases,  applied  by  swab  every  two  hours,  or  a  spray 
of  the  liquid  diluted  with  seven  times  its  bulk  of  water.  He 
states  that  it  neither  acts  as  a  solvent  to,  nor  prevents  the 
formation  of,  false  membrane,  bat  neutralizes  its  poison. 

The  form  in  which  this  agent  has  been  most  generally  used 
in  this  city  is  the  Marchand  solution,  which  contains  fifteen 

1  Brooklyn  Medical  Journal,  May,  1888. 
2Archiv.  f.  Kinderh.,  B.  viii.,  H.  2,  p.  113. 

3  Wiener  Med.  Presse,  1886,  xxvii.,  18,  19. 

4  Archives  of  Paediatrics,  Feb.,  1888,  p.  102. 


TREATMENT.  189 

volumes  of  the  gas.  Dr.  H.  Gifford,1  having-  in  a  series  of  ex- 
periments demonstrated  that  this  preparation  promptly  kills 
bacteria  and  their  spores,  adds,  "  The  instructions  accompany- 
ing- the  Marchand  solution  advise  diluting  with  about  four 
times  its  bulk  of  water  for  use  on  '  mucous  membranes  as  in- 
jections, etc'  A  dilution  of  this  strength  was  found  not  to 
have  killed  the  pus  cocci  after  an  exposure  for  thirty  minutes, 
a  result  which  practically  bars  it  as  a  germicide,  though  for 

its  cleansing  action  it  may  still  be  valuable The  fifteen 

volume  solution  is  sharply  irritating  to  the  conjunctiva  and 
nasal  mucous  membrane,  and  even  the  weakest  solution  men- 
tioned in  the  announcement,  instead  of  being  '  bland  as  water,' 
causes  considerable  smarting  of  the  eyes  and  nose  for  a  few 
minutes." 

I  have  tried  the  Marchand  solution  in  several  cases  of 
diphtheria,  including  one  adult  one,  and  my  experience  with  it 
accords  with  that  of  Dr.  Gifford  as  to  its  somewhat  irritating 
and  unpleasant  effect  when  used  with  only  slight  dilution.  In 
each  case  it  was  a  relief  to  the  patient  and  therapeutically 
advantageous  when  its  use  was  discontinued  and  my  usual 
spray  of  carbolic  acid  and  lime-water  was  resumed. 

In  a  case  related  to  me  by  another  physician  in  which  the 
peroxide  was  employed  early  and  frequently  both  as  spray 
and  internally,  the  duration  of  the  disease  was  not  shortened 
thereby,  and  the  patient  died  just  at  the  time  of  apparent  re- 
covery from  the  usual  effects  of  toxic  absorption,  which  the 
remedy  had  failed  to  counteract. 

In  so  far  as  I  have  been  able  to  judge  of  its  effects  the 
peroxide  of  hydrogen,  though  it  is  a  valuable  antiseptic,  has 
no  greater  curative  efficiency  in  the  treatment  of  diphtheria 
than  the  solutions  of  chlorine  or  of  permanganate  of  potas- 
sium, with  which  remedies  it  may  be  classed;  but  is  to  be  pre- 
ferred to  them  on  account  of  its  less  disagreeable  taste. 

The  application  of  ozone  by  the  inhalation  of  ozonized  air 
1  New  York  Medical  Record,  Sept.  1,  18S8,  p.  243. 


190  diphtheria;   its  nature  and  treatment. 

has  been  from  time  to  time  recommended  in  the  treatment  of 
diphtheria — the  ozone  being-  produced  by  a  chemical  process  in 
an  inhaler.  Dr.  Seneca  D.  Powell  a  few  years  since  exhibited 
to  the  Post-graduate  Clinical  Society  of  this  city  an  inhaler  in 
which  ozone  is  generated  by  the  action  of  electricity,  and  which 
he  had  used  with  good  effect  in  various  diseases,  among  which 
was  diphtheria  in  several  cases — its  effect  having  been  the 
rapid  disappearance  of  false  membrane  and  the  correspond- 
ingly rapid  reduction  of  temperature.  I  am  informed  by  the 
deviser  of  this  instrument,  Mr.  Harvey  Lufkin  of  the  C.  &  C. 
Electric  Motor  Company,  that  it  will  soon  be  manufactured 

# 

and  offered  for  sale. 

Benzoate  of  Sodium. 

Benzoate  of  Sodium  has  only  a  mild  antiseptic  action,  since 
in  a  solution  of  ^oir  i*  merely  hinders  the  growth  of  anthrax 
bacilli  (Koch).  Letzerich,  having  been  led  by  the  experiments 
of  Graham  Brown  to  the  conclusion  that  it  is  fatal  to  the 
microbe  of  diphtheria,  and  consequently  a  specific  for  that  dis- 
ease, employed  it  therapeutically  with  nearby  uniform  success 
by  the  following  formula : 

#     Sodii  benzoat,     .        .        .        .         3  j.  gr.  xv. 

Syr.  aurantii,      .        .        .        .         3  ijss. 

Aquae  menthae  pip., 

Aquae  dest.,         .        .        .         aa     §  j.,  3  ij. 

M. 
To  be  given  in  divided  hourly  doses  in  the  twenty-four 
hours.     He  subsequently  increased  the  daily  dosage  to  from 
1|  to  3|  drachms  to  children  under  fifteen  years,  and  from  3| 
to  5^  drachms  for  older  patients. 

From  this  and  similar  uses  of  it  favorable  results  have 
been  reported  by  Kien,  Ferreol  and  manj^  others,  the  most 
notable  being  those  related  by  Brondel,1  who  claimed  to  have 
treated  two  hundred  cases  with  uniform  success  by  the  fol- 

1  Bulletin  Gen.  de  Therap.,  Nov.  15,  1886,  p.  416. 


TREATMENT.  191 

lowing-  method :  He  gave  hourly  a  tablespoonful  of  a  solution 
of  the  benzoate  (fifteen  grains  to  the  fluid  ounce),  together 
with  one  sixth  of  a  grain  of  the  sulphide  of  calcium  in  syrup 
or  granule,  and  sprayed  the  throat  every  half-hour  with  a  ten 
per  cent,  solution  of  the  benzoate.  He  also  employed  vapori- 
zation of  water  containing  carbolic  acid,  turpentine  and  oil  of 
eucalyptus. 

Favorable  results  from  the  use  of  the  benzoate  of  sodium 
have  not,  however,  been  obtained  by  all  who  have  employed  it. 
Thus  Guandige,  of  Vienna,1  among  seventeen  children  treated 
by  the  method  of  Letzerich,  had  eight  deaths.  While  there  is 
reason  to  believe  that  this  agent  has  positive  therapeutical 
value,  the  hope  that  it  would  prove  to  be  the  desired  specific 
has  not  been  realized. 

Chlorate  of  Potassium. 

Chlorate  of  Potassium  has  long  held  a  leading  place 
among-  valuable  remedies  in  the  treatment  of  diphtheria.  It 
is  a  mild  antiseptic,  and  its  effect  in  favorably  modify- 
ing catarrhal  inflammation  in  the  mucous  membrane  of  the 
mouth  and  throat  is  well  established.  It  is  to  this  effect  upon 
the  inflammation  that  its  utility  in  the  treatment  of  diph- 
theria is  doubtless  mainly  due. 

The  important  fact  that  chlorate  of  potassium  is  in  exces- 
sive doses  a  most  dangerous  poison  has  been  illustrated  in 
quite  numerous  instances.  Dr.  V.  Afanasieff 2  has  collected 
from  international  literature  fifty-one  such  cases,  forty-six  of 
which  were  fatal.  He  has  also  found  by  experiments  on  ani- 
mals that  in  acute  cases  of  poisoning  by  the  chlorate  of  potash 
there  is  rapid  and  profound  disorganization  of  the  blood,  its 
detritus  accumulating  in  the  liver,  spleen,  lymphatic  glands, 
bone-marrow    and    kidneys,   the  urinary    tubules   becoming 

1  Quoted  by  Le  Gendre,  loe.  cit. 

5 "St.  Petersburg  Inaugural  Dissertation,"  1885,  Abstracted  in  Pro- 
vincial Medical  Journal,  March,  1888,  p.  134. 


192  DIPHTHERIA;    ITS   NATURE    AND   TREATMENT. 

blocked  up  and  impassable,  the  renal  functions  ceasing  and 
acute  parenchymatous  nephritis  with  ureemic  poisoning-  re- 
sulting-. In  chronic  <cases,  parenchymatous  nephritis  is  soon 
followed  by  intense  interstitial  nephritis  with  its  usual  conse- 
quences; and  in  all  cases  the  blood  assumes  a  characteristic 
chocolate  color. 

The  cases  of  poisoning  referred  to  have  been  the  result  of 
taking  at  one  dose  known  quantities  of  the  salt  varying  from 
three  to  ten  drachms,  or  the  reckless  swallowing  of  large 
quantities  of  a  saturated  solution  or  super-saturated  mixture. 

These  facts  show  that  this  drug,  like  most  other  valuable 
therapeutical  agents,  is  a  poison  when  used  in  certain  quanti- 
ties, and  make  it  incumbent  on  physicians  not  only  to  exercise 
due  moderation  in  the  doses  of  it  which  they  prescribe  to  their 
patients,  but  also  to  correct  the  prevailing  popular  belief  that 
it  can  safely  be  taken  in  unlimited  quantities ;  but  thev  do  not 
teach  that  when  used  in  suitable  doses  and  in  proper  dilution 
it  is  liable  to  have  an  injurious  cumulative  effect,  which  is 
indeed  contradicted  by  a  vast  array  of  experience. 

Dr.  H.  Seeligmiiller 1  refers  to  the  experience  of  Dr.  von 
Mering  as  corroborating  his  own,  that  the  chlorate  of  potas- 
sium is  a  most  valuable  remedy,  and  is  only  dangerous  when 
given  on  an  empty  stomach,  so  as  to  be  rapidly  absorbed  into 
the  circulation  in  large  quantity.  Dr.  Seeligmuller's  doses 
(from  half  a tablespoonful  to  a tablespoonful  of  a  five  percent, 
solution  hourly)  are  large  enough  to  require  this  caution  in 
their  use. 

Dr.  Hiillmann,3  of  Halle,  who  uses  a  four  per  cent,  solution 
in  hourly  doses  of  from  a  teaspoon ful  to  a  tablespoonful,  has 
always  had  good  results  and  never  any  bad  effects  therefrom. 
In  twenty  years  he  has  used  this  remedy  for  3511  patients,  in- 
cluding 571  cases  of  diphtheria.  Among  the  latter  he  has  had 
only  six  deaths.     In  diphtheria  he  has  used  also  lime-water 

1  Deutsche  Med.  Wochenschr.,  45,  1883. 

2  Deutsche  Med.  Wochenschr.,  52,  1883. 


TREATMENT.  193 

and  weak  solutions  of  permanganate  of  potassium  locally. 
He  regards  chlorate  of  potassium  as  the  hest  of  all  remedies 
which  have  been  proposed  for  the  treatment  of  diphtheria. 
Similar  statements  have  been  made  by  many. 

During-  the  past  twenty  years  I  have  prescribed  the  chlo- 
rate of  potassium  in  thousands  of  cases  of  sore  throat  and 
scarlatina,  and  in  many  hundreds  of  cases  of  diphtheria,  usu- 
ally in  a  four  per  cent,  solution.  Many  of  these  patients  have 
taken  it  in  teaspoonful  doses  hourly  or  half-hourly  for  several 
weeks  continuously.  In  no  instance  have  I  observed  or  had 
any  reason  to  think  that  its  effect  has  been  injurious.  So  far 
from  its  having'  occasioned  kidney  affections  in  my  cases  of 
scarlatina  and  diphtheria,  the  infrequency  of  nephritis  and 
albuminuria  has  been  remarkable  even  in  many  very  grave 
cases  of  the  latter  disease. 

I  have  never  regarded  it  as  a  specific,  but  rather  as  a  valu- 
able adjuvant  in  the  treatment  of  diphtheria,  and  have  usually 
employed  it  in  connection  with  other  remedies.     (See  page  219 ). 

Borax.. 
Borax  is  a  very  valuable  antiseptic.  It  is  especially 
adapted  to  local  use  in  the  treatment  of  diphtheria  by  its 
bland  and  unirritating  character,  its  cleansing  effect,  and  its 
harmlessness  in  ordinary  doses.  It  has  therefore  been  much 
employed  in  the  form  of  the  glycerine  of  borax  applied  by 
brush;  in  powder,  by  insufflation;  and  in  a  watery  solution  of 
the  strength  of  from  one  to  five  per  cent,  by  gargling  or  irri- 
gation. 

The  following  combination  is  recommended  by  Le  Genclre : 1 
IJ .   Boracis, 

Potassii  chloratis,  aa  gr.  75. 

Acidi  carbolici, gr.    4. 

Glycerini, 3    2|. 

Mellis, 3    H- 

M.     To  be  applied  with  pencil. 

1  Archiv.  de  LaryngoL,  No.  1,  1887. 
18 


194  diphtheria;   its  nature  and  treatment. 

Dr.  Noel"1  has  lately  announced  that  he  has  given  borax 
internally  with  good  results  in  the  following"  doses : 

To  children  under  one  year  .        8  to  15    grains  daily 

"        from  two  to  five  years    15  to  23        "  " 

"      five  to  ten  years     30 

"     adults  45,  60  or  75  " 

These  quantities  are  given  in  solution  in  divided  doses 
hourly. 

The  drug  produces  abundant  salivation.  Dr.  Noel  thinks 
that,  being  eliminated  by  the  salivary  glands  and  the  mucipar- 
ous glands  of  the  throat,  it  tends  to  soften  and  remove  the 
false  membrane.  This  was  the  only  medicine  given  during  an 
epidemic  to  sixty  patients,  of  whom  only  two  or  three  died. 

Boracic  acid  has  been  preferred  and  employed  by  some.  It 
may  be  locally  applied  in  saturated  solution  and  used  as  a 
gargle  or  in  spray  in  a  solution  of  the  strength  of  from  one 
to  three  per  cent. 

Oil  of  Turpentine. 

Oil  of  Turpentine  is  a  powerful  antiseptic.  In  a  solution  of 
the  strength  of  tt.Wo  ^  hinders  the  growth  of  bacteria.  The 
vapor  of  oil  of  turpentine  mixed  with  air  arrests  the  secretion 
of  mucus.  The  drug  when  taken  internally  is  partly  excreted 
by  the  lungs  and  acts  on  the  mucous  membrane,  lessening  its 
secretion;  but  a  watery  solution  of  it  applied  to  inflamed 
mucous  membranes  increases  secretion  and  diminishes  vascu- 
lar congestion.  Large  doses  are  liable  to  act  as  a  purgative, 
and  moderate  ones  are  apt  to  cause  dysuria  and  haematuria. 

Oil  of  turpentine  has  been  used  by  some  as  a  local  applica- 
tion. Schmiedler 2  prefers  it  to  any  other.  He  applies  it  pure 
in  cases  in  which  the  seat  of  the  affection  is  accessible  every 
three  hours,  and  finds  that  it  is  unirritating,  rapidly  dissolves 
false  membrane,  and  has  a  very  decided  antiseptic  action. 

1  Le  Concours  M6d.,  May  26,  1888. 

2  Rev.  Mens,  des  Mai.  de  l'Enf.,  June,  1888. 


TREATMENT.  195 

There  is  much  recent  testimony  to  the  benefit  derived  from 
the  internal  use  of  oil  of  turpentine  in  the  treatment  of  diph- 
theria, especially  in  the  laryngeal  form  of  the  disease. 

Bosse *  gave  eight  grammes  (two  drachms)  to  children  of 
from  two  to  seven  years  of  age,  and  twelve  grammes  (three 
drachms)  to  older  patients,  pure,  followed  by  milk,  once  daily 
in  forty-three  cases,  including'  very  severe  ones,  with  distinct 
effect  in  modifying  and  shortening  the  disease,  and  with  only 
two  fatal  results. 

Dr.  Satlow 2  followed  Bosse's  method  in  forty-three  severe 
cases,  adding  one  gramme  (Trixv.)  of  ether  to  fifteen  grammes 
(f.  3  iij.,  gr.  xlv.)  of  turpentine  to  diminish  its  nauseating  effect. 
In  three  cases  the  imminent  necessity  of  tracheotomy  was 
obviated  by  the  treatment,  and  only  three  per  cent,  of  his 
patients  died. 

Dr.  Roese3  treated  fifty-eight  cases  by  the  following 
method:  Teaspoonful  doses  of  oil  of  turpentine  (with  four 
minims  of  ether  in  each  dose)  were  given  three  times  a  day. 
A  tablespoonful  of  a  two  per  cent,  solution  of  salicylate  of 
sodium  was  given  every  two  hours;  a  warm  one  per  cent, 
solution  of  potassium  chlorate  was  used  as  a  gargle,  and  an 
ice-bag  was  applied  externally.  His  results  were,  rapid  sub- 
sidence of  fever  and  subjective  symptoms,  no  exacerbation  of 
the  local  affection  after  the  commencement  of  treatment, 
obviation  of  the  danger  of  asphyxia,  except  in  one  case  in 
which  tracheotomy  was  performed,  and  decided  shortening  of 
the  duration  of  the  disease.  The  turpentine  was  discontinued 
as  soon  as  the  fever  had  subsided  and  the  local  symptoms  had 
improved.  In  most  cases  not  more  than  from  three  to  five 
drachms  were  required,  though  in  several  instances  as  much  as 
fifteen  drachms  was  employed.    Only  three  of  his  patients  died. 

Dr.  A.  Sigel,4  in  the  Olga  Hospital  in  Stuttgart,  treated 

1  Berlin.  Klin.  Woehenschrift,  No.  43,  1880,  and  No.  10,  1881. 

2  Deutsche  Med.  Zeitschrift,  1883,  p.  157. 

3  Therapeutische  Monatschefte,  October,  1887. 
d  \rch.  f.  Kinderh.,  vi.,  2. 


196 


diphtheria;  its  nature  and  treatment. 


forty-seven  cases,  including"  some  very  grave  ones,  with  tur- 
pentine in  teaspoonful  doses  once  or  twice  daily,  with  seven 
deaths,  or  14.9  per  cent.  In  four  of  these  cases  the  necessity 
of  tracheotomy  was  imminent,  hut  was  averted  hy  the  treat- 
ment. Of  sixteen  other  patients  treated  with  salicylic  acid, 
chlorate  of  potash,  etc.,  seven  died,  or  43  per  cent.,  and  of 
twenty-four  treated  with  sublimate  six  died,  or  25  per  cent. 

Dr.  S.  Baruch,1  from  his  favorable  experience  in  the  use  of 
this  remedy  in  39  cases,  says :  "  In  only  one  case  have  I  observed 
temporary  hematuria ;  in  none  strangury  ....  I  administer 
ol.  terebinth,  in  doses  of  one  drachm  to  half  an  ounce  to  chil- 
dren from  six  to  fourteen  years  of  age,  once  a  day,  oftener  in 
cases  demanding  it.  It  may  be  given  pure,  followed  by  milk  or 
mixed  with  milk  or  in  emulsion.  Vomiting  occurs  sometimes 
after  the  first  dose,  but  it  is  usually  retained  afterwards.  In 
about  fifty  per  cent,  of  the  cases  it  produces  a  laxative  effect. 
It  always  stimulates  the  secretions  of  kidneys  and  skin;  the 
odor  is  quickly  detected  in  these  as  well  as  in  the  fseces." 

In  the  Oldenburg  Hospital  for  Children  in  St.  Petersburg, 
264  of  296  very  grave  cases  of  diphtheria  were  treated  in  1882, 
according  to  the  report  of  Dr.  Lunin, 2  in  different  groups  by 
the  following  remedies  and  with  the  following  results  in 
"  fibrinous  "  and  "  septic  "  cases  respectively : 


Fibrinous  Form. 

Septic  Form. 

Totals. 

Treatment. 

Percent- 

Percent- 

Rate 

Cases. 

Deaths. 

age  of 
Deaths. 

Cases. 

Deaths. 

age  of 
Deaths. 

Cases. 

Deaths. 

Per 
Cent. 

Bichloride    .     . 

43 

13 

30.2 

14 

13 

92.9 

57 

26 

45 

Chloride  of  iron 

43 

14 

32.6 

51 

39 

76.5 

94 

53 

56 

Chinoline     .     . 

19 

6 

31.6 

9 

9 

100 

28 

15 

53 

Resorcin  .     .     . 

10 

2 

20 

19 

17 

89 

29 

19 

65 

Bromine  .     .     . 

15 

7 

46.7 

18 

16 

88.9 

33 

23 

69 

Turpentine .     . 

12 

1 

8.3 

11 

9 

81.8 

23 

10 

43 

264 

146 

55.3 

1 "  Therapeutical  Memoranda  on  Diphtheria,  with  Special  Reference 
to  the  Value  of  Large  Doses  of  Oil  of  Turpentine,"  New  York  Medical 
Record,  Dec  24,  1887,  p.  784. 

2  St.  Petersburg  Med.  Wochenschr.,  6  and  7,  1885. 


TREATMENT.  197 

The  bichloride  was  applied  locally  by  brushing  with  a  y^ 
solution  every  two  hours  and  irrigation  with  a  T5Vo  solution 
hourly. 

The  chloride  of  iron  was  given  iu  doses  varying  from  one 
drop  every  two  hours  to  two  drops  every  half -hour,  with  irri- 
gation every  hour  by  a  three  per  cent,  solution  of  boric  acid. 

Quinoline  was  applied  every  two  hours  in  five  per  cent, 
solution  in  water  and  alcohol,  and  used  by  irrigation  or  spray 
in  -gJg-g-  solution. 

Resorcin  was  applied  in  ten  per  cent,  solution  every  two 
hours,  and  used  in  one  per  cent,  solution  as  gargle  or  spray. 

Bromine  was  used  in  -gfo  solution,  applied  every  one  to 
three  hours,  and  in  a  solution  two  thirds  of  that  strength  in- 
haled every  half -hour  to  every  hour. 

Turpentine  was  given  in  doses  not  exceeding  ten  drops 
hourly  for  periods  of  from  two  to  ten  days,  with  a  gargle  of  a 
three  per  cent,  solution  of  boric  acid. 

In  thirty-two  additional  cases  treated  by  other  methods 
there  were  eighteen  deaths,  or  56  per  cent.  The  mortality  in 
the  entire  series  of  296  cases  was  therefore  164,  or  55.4  pei 
cent. 

These  figures  show  the  best  results  from  turpentine  in  the 
fibrinous  form,  and  the  worst  from  bromine;  the  best  from 
Chloride  of  iron  in  the  septic  form,  the  worst  possible  from 
chinoline,  and  nearly  as  bad  from  bichloride  of  mercury. 

Antiseptic  Aero-therapy. 

Oil  of  turpentine  has  been  much  employed  by  vaporization. 
It  may  be  poured  from  time  to  time  into  a  vessel  in  which 
water  is  kept  constantly  at  boiling  point,  and  the  vapor  may 
be  allowed  to  diffuse  itself  through  the  air  of  the  room  or  con- 
ducted through  a  tube  near  to  the  patient's  mouth.  Dr.  Del- 
thil 1  recommends  that  in  cases  of  no  especial  gravity  it  be 
evaporated  by  placing  it  in  a  suitable  vessel  which  is  set  into 
1  Journal  de  M6d.  de  Paris,  July  12,  1886. 


198  DIPHTHERIA;    ITS    NATURE    AND    TREATMENT. 

another  one  containing-  water  which  is  kept  at  a  temperature 
of  60°  C.  (140°  F.).  The  turpentine  should  be  crude,  not  recti- 
fied.    In  a  large  room  several  such  receptacles  should  be  used. 

He  recommends  the  employment  of  antiseptic  fumigations 
in  grave  cases  by  the  following  method :  A  mixture  of  two 
pounds  of  coal  tar,  four  ounces  of  oil  of  turpentine,  two 
drachms  of  resin  of  benzoin  and  three  and  one  quarter  ounces 
of  cajeput  oil,  or  a  mixture  of  seven  ounces  of  coal  tar  and  two 
ounces  and  six  drachms  of  turpentine,  or  turpentine  alone 
may  be  used.  About  two  ounces  of  either  is  poured  into  a 
large  metallic  dish,  and  then  lighted  and  allowed  to  burn 
steadily,  renewal  being  required  about  once  in  two  hours.  A 
small  room  should  be  used  for  the  purpose,  into  which  the 
patient  may  be  carried  and  allowed  to  remain  for  half  an  hour 
at  a  time,  after  which  he  may  be  returned  to  the  regular  bed- 
chamber, in  which  the  evaporation  of  turpentine  by  the  method 
previously  described  is  maintained.  Dr.  Delthil  has  found 
that  the  fumes  are  well  tolerated  by  patients,  and  reports 
favorable  results  from  this  method  of  treatment  in  one  hun- 
dred and  twenty-six  out  of  one  hundred  and  thirty-four  cases. 

Renou 1  reports  the  successful  employment  of  the  following 
method  of  antiseptic  aerotherapy:  On  one  or  two  small 
kerosene  stoves  water  is  kept  constantly  at  the  boiling-point. 
Into  this  is  put  every  two  hours  one  or  two  drachms  of  the 
following  mixture:  Alcohol,  468  grammes;  carbolic  acid,  280 
grammes;  benzoic  acid,  112  grammes;  and  salicylic  acid,  156 
grammes.  The  apparatus  must  be  so  placed  that  the  vapor 
can  be  readily  inhaled  by  the  patient. 

Eucalyptus. 

Dr.  J.  Murray-Gibbes 2  extols  the  virtues  of  eucalyptus  used 
in  the  following  manner :  The  patient  is  kept  in  an  improvised 

bulletin  de  Soe.  de  MeU  d' Angers,  1885,  xiii.,  p.  112. 
2  London  Lancet,  1883,  i.,  p.  316,  and  Australian  Medical  Journal, 
October  15,  1888. 


TREATMENT.  199 

tent,  and  the  air  is  charged  with  vapor  impregnated  with  the 
oil  of  eucalyptus,  by  placing  the  dried  leaves  in  a  vessel  of 
boiling  water  beside  the  bed.  This  should  be  renewed  every 
half-hour.  The  patient  is  kept  in  this  atmosphere  until  the 
disease  has  disappeared.  Dr.  Murray  Gibbes  has,  since  1881, 
treated  163  patients  in  this  way,  with  only  one  death,  though 
other  physicians  have  lost  many  patients.  A  colleague  has 
treated  305  cases  in  the  same  manner  with  only  one  death. 

Thymol,  which  is  a  powerful  antiseptic,  has  been  utilized  in 
the  treatment  of  diphtheria.  It  may  be  used  by  the  following 
formula,  as  gargle  or  spray:1  Thymol,  3j.;  Glycerine,  3  iij..; 
Water,  §  jss.  Oil  of  peppermint,  which  is  also  strongly  anti- 
septic, has  been  found  efficient  used  "  freely  and  copiously"  as  a 
local  application  twice  daily  in  the  early  stage  of  diphtheria.2 
The  insertion  into  the  nostrils  of  plugs  of  cotton  saturated 
with  a  twenty  per  cent,  oily  solution  of  menthol  in  cases  in 
which  the  nares  were  entirely  occluded  with  membrane  is  said 
to  have  caused  its  rapid  disappearance  and  the  arrest  of  the 
diphtheritic  process.3  Engelmann 4  has  found  that  vinegar  is 
a  most  efficient  antiseptic.  Used  pure  for  local  application, 
diluted  with  two  or  three  parts  of  water  as  spray,  and  with 
four  parts  of  water  as  a  gargle,  it  has  given  better  results 
than  any  other  agent.  It  is  energetic  without  being  irrita- 
ting. It  also  possesses  in  a  high  degree  the  power  of  pene- 
trating animal  tissues.  Citric  acid  in  the  form  of  lemon-juice 
has  also  been  highly  recommended  by  Fieuzal5  and  others. 

Dr.  Jules  Simon,  of  Paris,6  employs  the  following  local  treat- 
ment :  Local  application  every  hour  by  day,  and  every  two 
hours  at  night  of  lemon-juice  or  vinegar  or  pure  red  wine,  and 
gargling  or  irrigation  every  two  hours  with  a  hike- warm  solu- 

1  Dr.  Da  Costa,  N.  Y.  Med.  Record,  Feb.  27,  1880. 

2  Dr.  L.  Braddon,  London  Lancet,  March  24,  1888. 
3Cholewa,  in  Therap.  Monatsch.,  1888, 11,  p.  284. 
4Centr.  f.  Klin.  Med.,  1886,  No.  14. 

6  Bull,  de  la  clin.  nat.  ophth.,  vol.  vi.,  p.  57. 
6  Rev.  Mens,  des  Mai.  de  FEnf.,  August,  1885. 


200  diphtheria;  its  nature  and  treatment. 

tion  of  boracic  acid  (1 :  25)  or  borax  (1 :  50)  or  potass,  chlorat. 
(1 :  25)  or  lime-water  or  vinegar-water. 

Hydronaphthal  with  Papain. 

Dr.  W.  C.  Caldwell,1  in  order  to  accomplish  at  the  same 
time  the  solution  of  false  membrane  and  local  disinfection  in 
the  treatment  of  diphtheria,  has  combined  a  peptonizing-  fer- 
ment and  an  antiseptic  in  one  mixture.  Having-  referred  to 
the  general  tendency  of  the  latter  class  of  substances  to  pre- 
vent the  action  of  the  former,  he  states  that,  nevertheless,  in 
one  case  of  diphtheria  in  which  he  used  bichloride  of  mercury 
with  papain,  "the  pseudo-membrane  was  readily  dissolved, 
and  the  temperature  fell  from  103°  to  99°  from  nine  A.  M.  to 
six  p.  m.  .  .  .  Hydronaphthal  is  a  powerful  antiseptic  which 
acts  in  a  neutral  or  acid  menstruum,  and,  besides,  is  not  poi- 
sonous. When  it  is  used  with  papain  to  spray  the  throat  in 
diphtheria,  the  membrane  rapidly  dissolves." 

Dr.  Caldwell  has  employed  the  following  mixture  in  the 
treatment  of  seven  cases  of  diphtheria : 

r>  Papain,  .        .        .        .        ..        •  3  ij. 

Hydronaphthal, gr.  iij. 

Acidi  hydrochlorici  dil.,        .         .         .  gtt.  xv. 

Aq.  destil., ad  §  iv. 

M. 

This  was  applied  by  "  spraying  the  throat  every  half -hour 
until  temperature  is  reduced  and  breathing  is  easy;  then 
every  hour,  unless  asleep.  In  these  cases,  when  the  spray 
was  used  thoroughly,  the  temperature  fell  in  from  four  to 
eight  hours."  To  be  effective,  the  spray  must  be  thoroughly 
and  directly  applied  to  the  affected  surfaces.  In  the  seven 
cases  referred  to,  the  result  of  the  treatment  was  favorable 
in  all  but  one— a  laryngeal  case  in  which  cyanosis  was  present 
when  treatment  was  begun. 

1  Archives  of  Pediatrics.  February,  1889,  p.  97. 


TREATMENT.  201 


The  Chloride  of  Iron. 


So  great  a  mass  of  clinical  evidence  as  to  the  value  of  the 
chloride  of  iron  in  the  treatment  of  diphtheria  has  "been  pre- 
sented to  the  profession,  and  that  value  is  now  so  generally 
recognized,  that  it  would  he  superfluous  to  adduce  statistics  to 
prove  it.  The  occasional  denials  of  its  efficacy,  based  on  expe- 
rience of  its  unsuccessful  employment,  which  appear  in  medi- 
cal literature,  may  he  regarded  as  merely  illustrating  the 
indisputable  fact  that  it  is  not  a  specific,  and  that  its  useful- 
ness is  subject  to  limitations. 

The  local  astringent  action  of  the  drug  has  already  been 
referred  to ;  it  is  also  a  valuahle  local  antiseptic.  Internally 
it  is  undoubtedly  the  most  efficient  known  antidote  to  the  poi- 
sonous action  of  the  putrefaction -products  of  diphtheria  in 
the  system  at  large.  It  evidently  does  not  produce  this  effect 
by  destroying  the  microbes  of  the  disease,  hut  by  reinforcing 
the  vital  processes  by  means  of  which  the  poisons  produced  by 
them  are  resisted,  destroyed  and  eliminated.  The  tendency  of 
these  poisons,  when  absorbed  into  the  circulation,  is  to  the 
rapid  production  of  anaemia  and  haemic  disorganization,  nerv- 
ous prostration,  and  the  consequent  arrest  of  all  vital  func- 
tions. "  Ferric  salts,  after  absorption  into  the  blood,  increase 
not  only  the  number  of  the  blood-corpuscles,  but  also  the  per- 
centage of  haemoglobin  contained  in  them,  and  may  also  cause 
a  little  free  iron  to  be  contained  in  the  serum.  By  thus  in- 
creasing oxidation  in  the  tissues  they  increase  the  functional 

activity  of  all  the  organs Iron  also  circulates  with  the 

bile,  and  it  is  probable  that  the  beneficial  effects  of  large  doses 
may  be  due  to  the  action  of  the  iron  upon  the  liver."  (Brun- 
ton.)  Iron  is  also  a  tonic  to  the  vascular  system,  and  ferric 
chloride  has  been  supposed  to  have  an  especial  stimulant 
action  on  the  nervous  sytem. 

The  internal  administration  of  the  chloride  of  iron  has  lit- 
tle effect  on  the  duration  of  the  membranous  affection.     In  the 


202  diphtheria;  its  nature  and  treatment. 

laryngeal  form  of  the  disease  it  is  probably  useless,  except  to 
oppose  concomitant  blood-poisoning,  and  as  a  tonic.  In  the 
distinctively  inflammatory  stage  and  form  of  diphtheria  its 
value  is  mainly  limited  to  its  local  astringent  and  antiseptic 
action  in  the  pharynx.  Its  special  and  unequalled  utility  is 
seen  in  its  preventing  or  limiting  the  occurrence  of  constitu- 
tional poisoning  and  counteracting  its  effects  in  the  septic 
form  or  stage  of  the  disease.  Its  power  to  accomplish  this 
object  is,  however,  not  unlimited.  It  is  inadequate  in  cases  in 
which  the  constitutional  poisoning  is  especially  rapid  and  in- 
tense, and  in  many  cases  in  which  other  essential  antiseptic 
measures  are  neglected,  as,  for  instance,  the  cleansing  of  the 
nares  in  nasal' diphtheria. 

There  are  unfortunately  other  limitations  to  its  utility.  In 
quite  a  number  of  cases  it  is  irritating  to  an  especially  sensi- 
tive throat,  and  it  sometimes  causes  vomiting.  These  effects 
may  depend  on  the  injudicious  manner  of  its  administration, 
but  in  some  cases  its  use  in  any  form  is  inadmissible. 

The  administration  of  large  amounts  of  the  drug  is  con- 
sidered by  many  a  sine  qua  non  to  obtaining  its  beneficial 
local  and  constitutional  effect. 

Dr.  Aubrun,1  in  1860,  recommended  its  use  in  very  frequent 
doses.  His  usual  mode  of  administering  it  was  to  have  from 
twentjT  to  forty  drops  of  an  aqueous  solution  of  the  perchlo- 
ride,  consisting  of  one  part  of  the  anhydrous  salt  in  three  parts 
of  water,  put  into  a  cup  of  water,  and  of  this  two  teaspoonfuls 
were  taken  by  the  patient  every  five  minutes  while  awake, 
and  every  fifteen  minutes  while  sleeping.  Robert  Druitt,2  in 
1861,  practiced  and  recommended  giving  it  in  doses  as  large 
as  two  drachms  every  two  hours.  Both  of  these  physicians 
reported  favorable  results  from  this  heroic  medication,  and 
like  results  from  similar  practice  have  been  reported  by  many 
subsequent  writers. 

1  Gaz.  Med.  de  Paris,  Nov.  26,  1860,  p.  765. 

2  British  Medical  Journal,  Feb.  23,  1861,  p.  208. 


TREATMENT.  203 

Dr.  A.  Jacobi '  says,  "To  be  of  any  efficacy  muriate  of  iron 
must  be  given  in  large  doses,  frequently  repeated.  Five  to 
fifteen  drops  every  quarter,  half,  or  every  hour  is  a  dose  that 
alone  fairly  tests  the  effective  powers  of  the  medicine." 

Dr.  J.  E.  Winters2  makes  the  important  discrimination 
that  "  where  there  is  marked  sepsis  and  tendency  to  capillary 
haemorrhages  the  dose  should  be  larger  than  in  a  case  of  a 
less  septic  and  more  marked  inflammatory  character,"  and 
recommends  that  in  the  former  type  of  the  disease  at  least 
one  drachm  of  the  tincture  should  be  administered  every  hour 
to  a  child  two  to  five  years  old. 

In  those  cases  in  which  a  marked  tendency  to  septic  poi- 
soning" is  manifested  the  use  of  the  drug  should,  if  necessar}^, 
be  pushed  toward  the  limit  of  tolerance,  and  from  one  to  three 
ounces  daily  may  succeed  where  less  would  fail.  But  such 
heroic  dosage  is,  in  actual  practice,  especially  in  the  treatment 
of  young  children,  attended  with  grave  difficulties,  and  is  for- 
tunately  in  the  great  majority  of  cases  unnecessary.  When 
other  appropriate  treatment  is  employed,  from  one  and  a  half 
to  three  drachms  of  the  tincture  of  iron  given  daily  will  usu- 
ally have  the  desired  effect. 

It  has  also  been  considered  necessary  by  some  that  the 
tincture  of  iron  be  administered  in  concentrated  form.  While 
this  may  doubtless  enhance  its  beneficial  local  effect  in  some 
cases,  it  may  have  an  irritating  effect  in  others.  But  the 
great  objection  to  administering  it  in  this  form  to  children  is 
the  fact  that  its  unpleasant  acrid  and  styptic  taste,  and  the 
smarting  which  it  often  occasions  is  very  liable  to  arouse  their 
violent  opposition  to  taking  it  and  necessitate  struggles,  the 
undesirableness  of  which  has  already  been  alluded  to.  That 
this  is  no  merely  fanciful  or  unusual  result  I  know  from  obser- 
vation in  many  cases.  The  evil  referred  to  may  be  obviated 
in  most  cases  by  giving  the  tincture  of  iron  in  six  or  eight 
parts  of  glycerine.     (See  formula  page  220.) 

1  American  Journal  of  Obstetrics,  1875,  p.  660.  2  Loe.  cit. 


204  diphtheria;   its  nature  and  treatment. 

Quinine. 

Quinine  lias  been  much  employed  in  the  treatment  of  diph- 
theria as  an  antiseptic,  an  antipyretic  and  a  tonic. 

It  hinders  the  growth  of  anthrax  bacilli  in  a  solution  of  the 
strength  of  -g^-  and  prevents  it  in  that  of  -^j.  It  may  doubt- 
less exert  a  valuable  local  antiseptic  action,  but  is  inferior  in 
this  respect  to  other  agents  which  are  less  disagreeable  to  the 
taste. 

High  temperature  is  generally  limited  to  the  early  and  in- 
flammatory stage  of  the  disease,  and  then  other  measures  for 
reducing  it  are  more  efficient  and  appropriate  than  antipyretic 
doses  of  quinine. 

For  tonic  effect  in  the  later  stage  of  the  disease,  and  in  the 
period  of  convalescence,  quinine,  in  doses  of  from  half  a  grain 
to  a  grain  or  two,  three  or  four  times  a  day,  or  the  compound 
tincture  or  wine  of  cinchona,  or  the  elixir  of  calisaya,  may  be 
very  useful. 

The  unpleasant  bitterness  of  quinine  and  its  consequent 
tendency  to  excite  nausea  are  important  obstacles  to  its  use 
in  the  treatment  of  diphtheria  in  young  children. 

Alcohol. 

The  antizymotic  and  antiseptic  actions  of  alcohol  are  well 
known.  It  hinders  the  growth  of  anthrax  bacilli  in  a  dilution 
of  1 :  100,  and  prevents  it  in  that  of  1 :  12.5.  Its  main  utility, 
however,  in  the  treatment  of  diphtheria  probably  results  from 
its  assisting  to  maintain  nutrition  and  opposing  the  tendency 
to  adynamia  and  heart-failure  by  its  action  as  a  food  and  a 
stimulant. 

The  principal  indications  for  its  use  are  the  following : 
When  milk  or  other  food  is  refused  by  the  patient  or  taken 
only  in  insufficient  quantities,  the  addition  of  a  little  brandy 
or  wine  will  sometimes  cause  it  to  be  relished  and  taken  more 
freely  and  will  also  promote  its  digestion. 


TREATMENT.  205 

In  marked  depression  of  the  vital  powers  from  the  com- 
bined effects  of  fever,  prolonged  suffering-,  fatigue,  loss  of 
sleep,  and  an  insufficiency  of  nourishing-  food,  even  if  the  symp- 
toms of  septic  poisoning  are  absent,  alcoholic  stimulants,  care- 
fully and  moderately  administered,  may  have  a  valuable  sus- 
taining effect,  as  in  other  diseases. 

At  the  first  appearance  of  symptoms  which  denote  consti- 
tutional poisoning  by  the  septic  products  of  the  disease,  such 
as  pallor  with  weakness,  enfeebled  heart-action,  etc.,  alcoholic 
stimulants  should  be  administered.  The  quantity  and  fre- 
quency of  the  doses  must  depend  on  the  gravity  of  the  symp- 
toms, the  effect  of  the  remedy  in  controlling  them,  and  the 
tolerance  of  the  stomach.  The  symptom  to  be  especially 
regarded  is  the  pulse.  If  that  be  feeble  and  •  unduly  slow  or 
rapid  or  irregular  the  amount  of  stimulant  given  must  be 
increased,  if  possible,  until  its  favorable  effect  is  manifested. 
Intoxication  in  the  ordinary  sense  of  the  term  is  not  usually 
produced  under  these  circumstances.  The  amount  given  must 
often  be  large,  and  may  sometimes  be  heroic.  I  have  in  many 
instances  given  three  or  four  ounces  of  brandy  or  whiskey  daily 
in  teaspoonful  doses,  well  diluted,  every  hour  or  half  hour  to 
children  under  five  years  of  age,  without  injurious  effect,  and 
in  some  cases  with  evident  benefit.  I  have  repeatedly  seen  it 
given  in  more  than  twice  that  quantity,  but  although  favora- 
ble results  are  reported  from  this  use  of  it  where  less  has 
failed,  I  have  never  seen  an  instance  of  them. 

Brandy  or  whiskey  may  be  given  in  the  form  of  milk  punch 
or  made  into  a  toddy  or  diluted  with  carbonated  waters;  or 
egg-nog  or  wine-whey,  or  Malaga,  Burgundy  or  port  wine 
may  be  more  acceptable  to  the  patient,  and  sometimes  cham- 
pagne has  a  particularly  good  effect. 

The  most  important  limitation  to  the  giving  of  alcoholic 
stimulants  in  diphtheria  results  from  the  intolerance  of  them  by 
the  stomach.  When  in  every  form  they  are  found  to  excite 
repugnance  or  nausea  and  to  thus  prevent  the  taking  of  other 


206  diphtheria;   its  nature  and  treatment. 

food,  persistence  in  their  use  can  only  be  injurious.  The  pos- 
sibility of  causing  subacute  gastritis  by  giving  too  strong 
and  too  frequent  doses  of  alcoholics  should  not  be  forgotten. 
"  Sometimes  when  given  very  freely  to  support  the  failing  cir- 
culation, they  have  this  effect,  the  result  of  which  is  that  both 
food  and  stimulants  are  vomited,  and  the  patient  is  brought 
to  death's  door."  (Brunton.)  In  view  of  the  close  sympathy 
which  is  well  known  to  exist  between  the  condition  of  the 
stomach  and  the  function  of  the  heart  through  the  nervous 
system,  it  is  evident  that  the  irritation  or  overtaxing  of  the 
former  by  too  heroic  stimulation  may  inhibit  the  latter,  and 
thus  produce  the  very  condition  of  heart-failure  which  it  was 
intended  to  prevent. 

The  indications  for  the  use  of  alcohol  which  have  been 
stated  by  no  means  justify  its  indiscriminate  use  in  the  treat- 
ment of  diphtheria.  It  is  not  called  for  in  the  early  stages  of 
most  cases.  It  is  in  no  sense  a  specific  for  diphtheria.  It 
should  be  remembered  that  when  it  is  used  without  indication 
or  in  excess  of  the  quantity  indicated,  though  it  may  in  some 
cases  be  well  tolerated,  it  is  yet  a  poison.  It  is  especially 
liable  to  be  so  to  the  dehcate  organizations  of  children.  "Ab- 
sorbed into  the  blood  it  lessens  oxidation,  and  will  conse- 
quently diminish  oxidation  in  the  tissues."  (Brunton.)  "  In  cer- 
tain circumstances,  such  as  febrile  diseases,  it  may  be  a  very 
useful  food;  but  in  health,  when  other  foods  are  abundant, it  is 
unnecessary,  and  as  it  interferes  with  oxidation  it  may  be  a 
very  inconvenient  kind  of  food."  (Ibid.)  "  By  increasing  the 
circulation  it  may  stimulate  the  functions  of  all  the  nerve- 
centres  and  render  them  for  the  time  being  capable  of  greater 
activity, ....  but  its  action  on  the  nerve-centres  themselves  is 

a  paralyzing  one Its  action  on  the  nerve-tissues  seems 

to  be  one  of  progressive  paralysis."  (Ibid.)  "  In  the  Ashan- 
tee  campaign  the  effect  of  alcohol  as  a  stimulant  compared 
with  beef -tea  was  carefully  tested.  It  was  found  that  when  a 
ration  of  rum  was  served  out  the  soldier  at  first  marched 


TREATMENT.  207 

more  briskly,  but  after  about  three  miles  had  been  traversed 
the  effect  of  it  seemed  to  be  worn  off,  and  he  then  lagged  more 
than  before.  If  a  second  ration  was  then  given  its  effect  was 
less  marked,  and  wore  off  sooner  than  that  of  the  first.  A 
ration  of  beef-tea,  however,  seemed  to  have  as  great  a  stimu- 
lating power  as  one  of  rum,  and  not  to  be  followed  by  any 
secondary  depression."     (Ibid.) 

The  wise  therapeutist,  in  the  treatment  of  diphtheria,  as  of 
other  diseases,  will  reserve  this  most  valuable  agent  to  aid 
him  in  tiding  his  patient  over  those  crises  in  which  its  use  is 
definitely  indicated,  rather  than  attempt  by  its  early,  indis- 
criminate and  excessive  administration  to  prevent  their  occur- 
rence— an  attempt  which  will  too  often  tend  to  defeat  its  own 
object. 

In  proportion  as  other  and  more  appropriate  measures  for 
preventing  the  occurrence  of  serious  septic  poisoning'  and  sus- 
taining the  strength  of  the  patient  are  early  and  efficiently 
carried  out,  the  proportion  of  cases  in  which  the  use  of  alco- 
holic stimulants  is  called  for  is  diminished.  I  was  thus  enabled 
to  say  in  my  second  report  (see  page  212 ) :  "  The  large  major- 
ity of  cases  in  the  present  series,  as  in  those  that  I  have  previ- 
ously reported,  have  been  treated  absolutely  without  them." 
That  the  cases  of  which  this  could  be  stated  were  neither 
doubtful  nor  trivial  ones  was  conclusively  shown  in  the  re- 
ports referred  to.  All  my  subsequent  experience  and  obser- 
vation have  tended  to  confirm  my  belief  that  in  a  large 
majority  of  all  cases  of  diphtheria  which  are  early  and  well 
treated  the  indications  for  the  use  of  alcoholic  stimulants 
which  have  been  referred  to  do  not  present  themselves,  and 
that  their  use  without  those  indications  is  not  advantageous, 
but  the  reverse. 

Dr.  J.  Lewis  Smith 1  relates  the  following  typical  experi- 
ence :   "Although  an  advocate  of  the  liberal  use  of  alcohol,  I 
cannot  regard  this  agent  as  a  specific.     When  I  commenced 
1  Diseases  of  Children,  p.  319. 


208  'diphtheria;  its  nature  and  treatment. 

serving-  in  the  New  York  Foundling-  Asylum  in  May,  1878,  the 
quarantine  wards  contained  four  children  between  the  ages 
of  three  and  five  years  who  had  been  sick  a  few  days  with 
severe  diphtheria,  and  it  was  evident  at  a  glance  that  they 
must  soon  perish  with  the  ordinary  mild  sustaining  treatment. 
Quinine,  iron,  the  most  sustaining  food  and  a  moderate 
amount  of  alcoholic  stimulants  were  being  given,  and  we  de- 
termined to  increase  the  Bourbon  whiskey  to  a  teaspoonful 
every  twenty  to  thirty  minutes,  day  and  night.  Neverthe- 
less, whatever  the  result  might  have  been  with  the  earlier 
commencement  of  this  treatment,  the  blood-poisoning  was 
now  too  profound,  and  one  after  the  other  died." 

Those  who,  unlike  Dr.  Smith,  regard  the  heroic  use  of 
alcohol  as  a  specific  for  diphtheria,  explain  such  failures  by 
the  lateness  and  insufficiency  of  its  administration.  I  know 
of  no  ground  for  the  assumption,  either  in  our  knowledge  of 
its  action  or  the  statistics  of  treatment.  I  have  seen  quite  a 
number  of  cases,  some  of  them  in  my  own  earlier  practice  and 
others  in  consultation,  in  which  as.  free  use  of  alcohol  as  that 
just  referred  to  was  begun  at  the  outset  of  grave  and  malig- 
nant cases,  and  failed  as  signally  to  arrest  the  fatal  progress 
of  the  disease.  Our  main  dependence  for  effecting  that  object 
must  be  on  the  early  employment  of  other  and  more  appro- 
priate measures,  to  which  alcoholic  stimulants  may  often  be  a 
most  valuable,  and  sometimes  an  indispensable,  adjuvant. 

Specifics. 
Copaiba  and  Cubebs. 
Copaiba  and  cubebs  were  formerly  very  extensively  used, 
especially  in   France,  in  the  treatment   of  diphtheria.    Dr. 
Trideau  x  claimed  to  have  employed  them  with  rapidly  success- 
ful  effect   in  more   than  three  hundred   cases.     The    former 
remedy  having  been  generally  abandoned  on  account  of  its  ir- 
ritant effect  upon  the  digestive  organs  the  latter  continued  to 
J  Traitement  de  l'angine  couenneuse  par  les  balsamiques,  Paris,  1874. 


TREATMENT.  209 

be  much  used.  It  was  given  in  the  form  of  the  oleoresin, 
either  in  capsules  or  in  emulsion  with  syrup  of  acacia,  in  doses 
of  from  1.50  grammes  (22^  minims)  to  3  grammes  (45  minims) 
daily.  M.  Sanne,1  having  employed  this  treatment  in  a  great 
number  of  cases,  states  that  he  has  never  observed  from  it 
any  well  demonstrated  action  which  can  compensate  for  the 
disgust  which  it  inspires  in  patients  and  its  tendency  to  excite 
purgation. 

Cardiac  Depressants. 
Veratrum  Viride. 

The  employment  of  depressing  remedies,  except  to  fulfill 
some  imperative  and  temporary  indication,  is  generally  con- 
demned and  avoided  in  the  modern  treatment  of  diphtheria. 
From  what  has  been  stated  elsewhere  (page  71)  as  to  the  usual 
character  of  the  disease  in  its  early  stages,  it  is  evident  that 
this  exclusion  should  not  be  too  indiscriminate  and  arbitrary. 
The  following  statements  by  Dr.  J.  M.  Boyd,2  of  Knoxville, 
Tennessee,  in  so  far,  at  least,  as  they  relate  to  the  early  stage 
of  certain  types  of  the  disease,  are  worthy  of  consideration : 

The  characteristic  pulse  of  diphtheria  is  described  as 
"  rapid,"  "  small,"  "  hard,"  "  tense,"  "  wiry."  The  speedy  re- 
duction of  this  rapidity  to  the  normal  or  sub-normal  rate  has 
in  his  experience  been  followed  by  the  mitigation  of  the  in- 
flammatory process  and  the  melting  away  of  false  membrane. 
He  employs  for  this  purpose  the  tincture  of  veratrum  viride, 
commencing  with  moderate  doses,  according  to  the  age  of  the 
patient,  and  increasing  them  until  the  desired  effect  upon  the 
pulse  is  produced.  To  an  adult  he  gives  three  drops  of  Nor- 
wood's tincture  every  two  hours,  increasing  by  one  drop  at 
each  dose  until  the  pulse-rate  is  brought  down  to  sixty  or 
seventy  per  minute.  One  child  two  years  of  age  required  five 
drops  and  another  seven  drops  every  two  hours  to  bring  the 

!Op.  cit.,  p.  402. 

2  New  York  Medical  Record,  1888,  33,  p.  627. 
14 


210  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

pulse  under  control.  When  nausea  results  the  dose  must  be 
increased  cautiously  and  omitted  occasionally.  Dr.  Boyd  re- 
gards this  practice  as  unattended  with  danger.  He  accom- 
panies it  with  the  use  of  other  appropriate  remedies.  In  proof 
of  its  value  he  refers  to  his  successful  employment  of  it  in 
sixty-seven  cases  of  unquestionable  diphtheria,  including  a 
fair  share  of  malignant  ones.  He  finds  the  most  probable  ex- 
planation of  its  efficacy  in  the  view  that  by  slowing  the  tired 
heart,  it  gives  the  rest  which  is  so  important  to  the  recupera- 
tion of  nerve-force. 

The  Treatment  of  Diphtheria  by  Irrigation. 

Dr.  G.  Guelpa 1  advocates  the  treatment  of  diphtheria  by 
the  early,  persistent,  copious  and  very  frequent  washing  of 
the  parts  which  are  affected  by  the  disease  or  are  threatened 
with  its  extension,  whether  in  the  pharynx,  nares  or  else- 
where. The  medicinal  agent  to  be  employed  is  a  secondary 
consideration.  Mild  solutions  of  the  chloride  of  iron  have 
proved  most  successful  in  his  hands,  but  he  admits  that  other 
solutions,  as  of  lime,  carbolic  acid  or  boric  acid  may  be  equally 
serviceable.  The  fountain-syringe  or  nasal  douche  may  be 
used  in  the  milder  cases,  but  when  the  resistance  to  the  passage 
of  fluid  requires  it,  more  forcible  methods  should  be  resorted 
to.  The  irrigations  should  be  practiced  every  quarter  of  an 
hour  by  day  and  every  half-hour  at  night.  Dr.  Guelpa  reports 
the  successful  employment  of  this  method  in  a  long  series  of 
cases  at  different  periods. 

The  Method  op  Treatment  which  has  been  Employed 
by  the  Author. 

In  a  paper  read  before  the  New  York  Academy  of  Medi- 
cine in  March,  1876,2  I  presented  statistics  of  one  hundred  and 

'Bulletin  Gen.  de  Therap.,  1887,  pages  255,  313,  362. 

2 "  Diphtheria  and  its  Treatment,  with  Statistics  of  One  Hundred 
and  Seventy-nine  Cases,"  Transactions  of  the  New  York  Academy  of 
Medicine,  1876,  p.  286. 


TREATMENT.  211 

seventy-nine  cases  of  diphtheria,  one  hundred  and  twenty-four 
of  which  had  been  visited  by  me  in  the  North  District  of  the 
Demilt  Dispensarj^  (the  eastern  part  of  the  Twenty -first  Ward 
of  this  chYy)  in  an  epidemic  of  the  disease  which  occurred  in 
1875.  That  the  epidemic  in  that  locality  had  been  especially 
severe  was  shown  in  the  paper  referred  to  and  the  subsequent 
discussion  by  statistics  of  the  Board  of  Health  and  also  by  the 
testimony  of  other  physicians.1 

The  results  of  the  treatment  employed  in  these  cases  were 
that  in  ninety-eight  of  the  one  hundred  and  twenty-four  dis- 
pensary cases  in  which  it  was  tested  with  some  degree  of  fair- 
ness, though  under  very  unfavorable  conditions,  there  were 
ten  deaths,  or  about  ten  per  cent.  In  the  remaining-  fifty-five 
cases  which  were  treated  by  the  same  method  under  more 
favorable  conditions  by  the  late  Dr.  E.  J.  Darken,  Dr.  W.  E. 
Bullard  and  myself,  there  were  only  two  fatal  results. 

In  a  communication  to  the  New  York  Medical  Record 
(January  12,  1878,  page  21)  I  reported  the  statistics  of  thirty- 
seven  dispensary  cases  which  had  been  treated  by  my  assist- 
ant physicians,  Dr.  W.  E.  Bullard  and  Dr.  D.  C.  Comstock, 
and  myself  in  1876 — the  results  being  that  in  thirty-two  of 
them  in  which  the  treatment  had  been  tested  with  some 
degree  of  fairness  there  had  been  three  deaths,  or,  again,  a 
little  less  than  ten  per  cent. 

That  these  very  favorable  results  might  not  be  confounded 

1  Dr.  H.  T.  Hanks  said :  "  Dr.  Billington's  success  was  truly  remark- 
able, for  he  well  knew  the  type  of  the  disease  as  it  had  appeared  in  the 
Twenty-first  Ward,  having  had,  in  his  private  practice  during  the  last 
five  years  in  that  district,  from  twenty  to  thirty  cases  every  year.  He 
knew  that  many  of  the  cases  attended  by  Dr.  Billington  had  been 
severe,  and  not  a  few  malignant.  Therefore  when  the  large  per  cent, 
of  recoveries  was  considered  a  cause  must  be  looked  for;  and  he  be- 
lieved that  two  excellent  reasons  could  be  found  for  this  satisfactory 
result.  One  was  the  kind  of  medicaments  used  locally  and  internally, 
and  the  other  was  the  great  care  he  bestowed  in  teaching  the  parents 
or  nurses  the  proper  manner  of  administering  the  remedies  presented. 
This  carrying  out  to  the  letter  every  little  detail  has  had  much  to  do, 
more  than  many  have  been  led  to  suppose,  in  the  cure  of  diphtheria. " 


212  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

with  the  numerous  reports  of  brilliant  therapeutical  triumphs 
based  on  inaccurate  diagnosis  or  the  exceptional  mildness  of 
the  cases  treated,  I  again  in  18S0  presented  to  the  Academy  a 
report *  of  equally  good  results  obtained  by  the  same  methods 
of  treatment  in  forty  consecutive  dispensary  cases,  the  genu- 
ineness of  which  and  the  severity  of  a  large  proportion  were 
kindly  attested  from  personal  examination  either  by  Dr.  A.  H. 
Smith  or  Dr.  W.  T.  White,  most  of  the  cases  having  also  been 
seen  by  a  number  of  other  competent  physicians. 

The  treatment  described  in  the  first  of  the  reports  referred 
to  consisted  mainly  in  the  use  of  the  tincture  of  the  chloride 
of  iron,  potassium  chlorate,  salicylic  acid  (in  solution  with  the 
sulphite  of  soda),  glycerine  and  lime-water,  by  frequent  in- 
ternal administration,  carbolic  acid  and  lime-water  by  very 
frequent  spraying,  and  the  thorough  cleansing  of  the  nares  in 
nasal  diphtheria  by  syringing  them  with  tepid  salt  water. 
Its  most  essential  features  are:  (1)  the  most  efficient  possible 
local  disinfection,  (2)  without  irritation,  (3)  by  frequent  appli- 
cations, which  are  (4)  so  pleasant  as  not  to  arouse  the  opposi- 
tion of  children  nor  unnecessarily  to  annoy  and  fatigue  older 
patients,  this  being  accomplished  (5)  by  means  of  formulas  and 
other  details  which  were  precisely  stated  and  their  importance 
insisted  on. 

To  avoid  unnecessary  repetition,  these  particulars  and  their 
application  in  the  treatment  of  the  various  stages  and  forms 
of  diphtheria  will  be  subsequently  stated  in  connection  with 
such  additional  therapeutical  measures  as  my  own  later  ex- 
perience and  the  experience  of  others  have  shown  to  be  most 
worthy  of  confidence.2  Those  which  are  now  especially  referred 
to  may  be  found  on  pages  215,  216,  219,  220,  225  and  226. 

1 "  Forty  Attested  Cases  of  Diphtheria,  with  Remarks  on  Diagnosis 
and  Treatment,"  New  York  Medical  Eeeord,  March  27,  1880,  p.  333. 

2  It  is  proper  to  state  in  this  connection  that  Dr.  A.  Jacobi,  in  a 
paper  entitled  "  Contributions  to  the  Pathology  and  Therapeutics  of 
Diphtheria,"  which  was  read  before  the  New  York  County  Medical 
Society  in  December,  1874, — more  than  a  year  before  the  reading  of  my 


TREATMENT.  2.13 

Testimony  to  their  successful  employment  of  this  mode  of 
treatment  has  been  given  by  many  physicians  either  in  pub- 
lished statements  or  in  letters  which  have  been  received  by 
me  from  all  parts  of  this  country  and  Canada. 

Some  of  these  letters  have  borne  witness  to  «its  efficacy 
not  only  in  diphtheria  as  it  occurs  in  this  city,  but  also  in 
malignant  epidemics  in  distant  localities.  An  especially  in- 
teresting- and  instructive  statement  to  that  effect  from  Dr. 
T.  Clowes  Brown,  of  Fredericton,  New  Brunswick,  Canada, 
was  published  by  me,  with  his  permission,  in  the  New  York 
Medical  Record,  January  12,  1878,  page  23. 

first  paper— and  published  in  the  American  Journal  of  Obstetrics,  vol. 
vii.,  page  628,  advocated  the  treatment  of  the  severer  forms  of  diph- 
theria by  large  and  frequent  doses  of  the  tincture  of  iron ;  the  treat- 
ment of  "simple  tonsillar  diphtheria"  with  "frequent  small  doses  of  a 
chlorate  combined  with  lime-water,  or  tinct.  ferr.  mur.  3  ss — 3  ij.  a 
day,  and  generally  mixed  with  a  little  glycerine,  principally  for  the 
purpose  of  keeping  the  remedy  in  longer  contact  with  the  diseased 
surface,  if  not  for  its  own  antifermentative  effect ; "  and  the  treatment 
of  nasal  diphtheria  by  thorough  cleansing  and  disinfection  of  the  nares 
by  syringing  them  every  hour  or  every  half  hour  with  "  two  to  four 
grains  of  carbolic  acid  to  the  ounce  of  water,"  or,  "  where  there  is  no 
smell,  lime-water,  pure  or   somewhat  diluted,  for  its  solvent  effect." 

This  mention  is  made  proper  by  the  priority  of  Dr.  Jacobi's  publica- 
tion, and  the  coincidence  in  our  therapeutical  recommendations  in  res- 
pect to  the  drugs  principally  employed  and  the  distinctive  principles 
which  I  have  above  enumerated  as  1,  2,  and  3. 

In  reference  to  these  circumstances  I  made,  in  a  foot-note  to  my  first 
report  above  referred  to,  the  following  statement : — "  There  is,  in  my 
opinion,  more  essential  and  valuable  truth  in  this  little  monograph " 
(Dr.  Jacobi's)  "  than  can  easily  be  found  elsewhere.  It  should  be  care- 
fully perused  by  all  students  of  this  much  perplexed  subject.  It  is 
pi'oper  to  state  that  while  I  coincide  with  Dr.  Jacobi's  views  in  almost 
every  particular  I  am  not  his  '  follower,'  except  in  the  order  of  publi- 
cation. My  own  pathological  conclusions  and  my  present  mode  of 
treatment  were  independently  arrived  at  (as  many  of  my  friends 
know)  before  his  paper  was  written  or  I  knew  anything  of  its  author's 
views." 

In  the  New  York  Medical  Record,  Feb.  23,  1878,  page  158,  I  pub- 
lished a  letter  from  the  late  Dr.  E.  J.  Darken,  who  was  House-Physician 
to  Demilt  Dispensary  from  1869  until  his  death  in  1886,  which  gave 
precise  confirmation  to  the  latter  statement. 


214         'diphtheria;   its  nature  and  treatment. 

The  Treatment  of  the  Early  Stage  of  Pharyngeal 
Diphtheria. 

The  special  indications  at  this  stage  of  the  disease  are  local 
disinfection,  the  subduing-  of  inflammation  and  the  reduction 
of  fever. 

The  patient  should  be  put  to  bed  in  a  clean,  well- ventilated 
and  yet  sufficiently  warmed  apartment,  from  which  unneces- 
sary articles  of  furniture  have  been  removed. 

If  the  attack  shows  a  tendency  to  severity  and  is  attended 
with  marked  febrile  symptoms,  calomel  should  be  given,  either 
in  a  single  purgative  dose  of  from  two  to  ten  grains  according 
to  age,  or,  preferably  in  most  cases,  in  divided  doses  of  from 
one  fourth  of  a  grain  to  one  grain  mixed  with  sugar  and  placed 
upon  the  tongue  every  half  hour,  everj^  hour  or  every  two 
hours,  until  a  purgative  effect  is  produced. 

Ice  in  small  pieces,  or  in  the  form  of  water-ices,  is  usually 
grateful  to  the  patient  and  should  be  given  frequently,  and  he 
should  be  permitted  to  drink  ice-cold  water  freely  if  he  craves  it. 

Frequent  cool  sponging,  especially  about  the  head,  face  and 
neck,  is  often  soothing  and  agreeable.  If  there  is  a  marked 
tendency  to  glandular  swelling,  compresses  frequently  wrung 
out  of  ice-water,  or  ice-bags,  may  be  applied  over  the  affected 
region. 

If  the  patient  is  seen  at  the  initial  stage  of  the  disease 
when  the  false  membrane  has  not  yet  acquired  much  thickness 
or  density,  and  if  his  age  and  the  accessible  location  of  the 
affection  make  it  practicable,  its  abortive  treatment  may  be 
attempted.  The  affected  spot  or  spots,  having  been  cleansed 
by  spraying  or  irrigation  and  then  dried  by  gently  touch- 
ing them  with  absorbent  cotton,  may  be  carefully  touched 
with  a  solution  of  the  bichloride  of  mercury  (yoVo  to  Too)  Dv 
means  of  a  camel's  hair  brush  or  a  soft  swab  applied  with 
gentle  pressure.  This  may  be  repeated  every  two  hours  (a 
mild  antiseptic  or  solvent  spray  being  frequently  emplo3Ted 


TREATMENT.  .  215 

in  the  intervals)  if  its  effect  seems  to  be  good,  but  if,  in  spite 
of  a  few  such  applications,  the  local  affection  increases,  its 
further  use  should  be  abandoned  as  only  likely  to  aggravate 
the  irritation. 

For  the  purpose  of  rapidly  dissolving  the  false  membrane 
solutions  of  pepsine,  trypsin  or  papain  may  in  some  cases 
be  advantageously  employed  at  this  stage  of  the  disease  by 
very  frequent  topical  applications  or  spraying,  as  has  been 
described  on  pages  167  et  seq. 

Under  the  same  circumstances  the  application  of  various 
caustic  or  astringent  antiseptic  agents,  such  as  the  nitrate  of 
silver,  the  tincture  of  iodine,  concentrated  solutions  of  carbolic 
or  salicylic  acid,  resorcin  or  chloral,  which  have  been  referred  to 
in  the  preceding  portions  of  this  chapter  and  the  mode  of  using 
them  described,  may  doubtless  in  some  cases  arrest  the  disease 
at  its  outset.  The  favorable  experience  of  some  in  the  use  of 
such  agents  has  been  stated,  and  also  its  limitations  and 
dangers.  It  has  formed  no  part  of  my  usual  treatment.  My 
favorable  experience  in  this  use  of  Monsel's  solution  or  the 
tincture  of  the  chloride  of  iron  has  been  referred  to,  but  even 
that  may  be  ineffective  and  irritating. 

If  the  patient  is  old  enough  to  permit  it,  the  throat  should 
be  sprayed  with  some  mild,  solvent,  antiseptic  and  antiphlo- 
gistic liquid  as  frequently  as  is  practicable.  I  know  of  none 
which  so  admirably  combines  these  qualities  or  has  so  good 
an  effect  under  ordinary  circumstances  as  the  following  mixt- 
ure:1 

B     Acidi  carbolici, t\[  x. 

Aquas  calcis, fl.  §  iv. 

M.  S. — To  be  applied  by  spraying  for  some  minutes  every 
half-hour. 

This  mixture  has  the  important  advantage  of  being  more 
agreeable  to  the  patient  in  its  taste  and  after-effect  than  any 
other  that  I  know  of.     Many  children  will  permit  its  use  that 
1  This  formula  was  published  by  me  in  1876. 


216 


diphtheria;  its  nature  and  treatment. 


would  oppose  that  of  any  other.  The  proportions  are  impor- 
tant, since  the  addition  of  a  few  drops  more  of  the  carbolic  acid 
makes  it  pungent  and  disagreeable.  That  in  a  solution  of  this 
strength  (T|s)  carbolic  acid  is  an  efficient  antiseptic  and 
antiphlogistic  has  been  shown  on  page  180.  The  valuable 
utility  of  lime-water  has  also  been  shown  on  page  165.  The 
spray  thus  administered  should  be  fine,  as  coarse  sprays  are 
unpleasant  and  irritating  to  diphtheritica] ly  inflamed  surfaces. 
Some  atomizers  which  are  now  in  very  general  use  are  ob- 
jectionable in  the  treatment  of  diphtheria  for  this  reason. 


Fig.  10.— The  Delano  (No.  558)  Atomizer. 


The  Delano  atomizer  makes  a  fine  spray,  and  is  in  every 
respect  a  convenient  and  suitable  instrument. 

All  atomizers  which  throw  a  fine  spray  are  liable  to  be  ob- 
structed' by  solid  particles.  Nurses  should  always  be  taught 
how  to  remove  this  obstruction  by  means  of  the  fine  wire 
which  comes  in  the  box  with  the  atomizer,  or  with  a  bristle. 
When  the  Delano  atomizer  cannot  be  obtained,  the  Davidson 
instrument  will  serve  a  very  good  purpose,  and  has,  indeed, 
some  special  advantages. 

The  point  of  the  atomizer  should  not  usually  be  thrust  into 
the  throat  of  the  patient,  but  should  be  held  several  inches 


TREATMENT.  217 

from  the  open  mouth.  The  spray  is  thus  diffused  over  the 
whole  surface  of  the  palate  and  pharynx.  In  most  cases  in 
which  the  mouth  is  opened  widely,  the  spray,  if  good  aim  is 
taken,  reaches  the  pharynx  freely.  In  some  cases,  however, 
it  is  necessaiy  to  carry  the  point  of  the  atomizer  further  back 
over  the  tongue  or  to  depress  the  tongue.  The  patient,  when 
old  enough,  can  usually  he  taught  to  do  this,  using  a  tongue- 
depressor  in  which  the  handle  is  at  a  right  or  obtuse  angle  to 
the  blade.  Nurses  or  parents  must  always  be  carefully  in- 
structed in  the  proper  use  of  the  atomizer. 

Other  mild  antiseptic  sprays  may  render  valuable  service 
in  cleansing  and  disinfecting  the  mouth  and  throat,  as,  for  in- 


CAVIDSON  RUBBER  CO.  DAVIDSON  RUBBER  CO. 

Fig.  11. — Davidson  Anatomizer,  No.  59.  Fig.  12. — Davidson  Anatomizer,  No.  6. 


stance,  solutions  of  permanganate  of  potassium  (3  to  5  grains 
to  the  ounce),  peroxide  of  hydrogen  (one  in  four  of  water), 
bichloride  of  mercury  (one  in  4000  to  10,000),  borax  or  boracic 
acid  (one  to  three  per  cent,  solution),  salicylic  acid  (one  in  500 
to  2000),  etc.  The  special  utilities  and  drawbacks  of  these  and 
other  valuable  substances,  and  also  the  manner  in  which  they 
may  be  employed,  have  already  been  stated. 

"When  the  solvent  ferments  are  applied  by  spraying,  the 
point  of  the  atomizer  should  be  carried  nearer  the  membrane 
to  be  dissolved  than  has  been  directed  in  other  cases,  that  the 
solvent  may  be  concentrated  upon  it. 

When  the  patient  is  too  young  to  voluntarily  permit  the 
use  of  the  spray  (most  children  over  three  j^ears  of  age  can 


218  diphtheria;  its  nature  and  treatment. 

with  tact  be  taught  to  take  the  pleasant  one  I  have  described) 
its  use  should  not  he  attempted,  and  reliance  must  be  placed 
on  internal  administration  and  irrigation.  Mild  antiseptic 
washes  can  be  applied  by  the  latter  method  when  their  use  is 
indicated  by  the  presence  of  viscid  and  offensive  secretions  in 
the  mouth  and  throat.  A  hard -rubber  syringe  with  a  straight, 
slender,  and  smoothly  rounded  tip  should  be  used.  According 
to  the  valuable  suggestion  of  Dr.  Gruelpa 1  it  is  not  necessary 
to  force  the  teeth  open,  but  the  tip  of  the  syringe  may  be 
slipped  between  the  teeth  and  the  cheek,  toward  the  angle  of 
the  jaw,  and  fluid  injected  will  freely  enter  the  mouth  and 
pharynx  behind  the  last  molars.  The  utmost  gentleness 
should  be  observed  in  doing  this ;  it  should  not  be  repeated 
oftener  than  once  in  two  or  three  hours,  and  never  unless  it  is 
indicated  by  the  presence  of  offending  material  which  cannot 
be  otherwise  readily  dislodged.  I  once  shared  the  enthusiasm 
of  Dr.  Guelpa  for  the  treatment  of  pharyngeal  diphtheria  by 
irrigation,  but  my  own  further  experience  has  been  that  while 
it  has  valuable  uses,  it  may  easily  be  made  excessive,  irritating 
and  injurious.  Warm  salt-water  (one  drachm  to  the  pint)  or 
either  of  the  mild  antiseptic  solutions  just  referred  to  is  a 
suitable  liquid  to  employ. 

The  necessary  cleansing  of  the  throat  may  usually  be  ef- 
fected by  the  frequent    internal  administration  of  suitable 

remedies. 

Internal  Medication. — Antipyretics. — It  should  be  remem- 
bered that  high  fever  at  this  stage  of  the  disease  in  primary 
and  uncomplicated  cases  is  the  concomitant  of  the  inflamma- 
tion, and  that  its  reduction  is  to  be  sought  mainly  by  the  em- 
ployment of  the  antiseptic  and  antiphlogistic  measures  which 
have  now  been  referred  to.  When  it  is  excessive  and  persist- 
ent I  know  of  no  antipyretic  drug  which  will  usually,  according 
to  my  experience,  yield  such  satisfactory  results  as  the  sali- 
cylate of  soda.     It  may  be  given  in  doses  of  from  two  to  fifteen 

!Op.  cit. 


TREATMENT.  219 

grains  in  from  a  teaspoonfnl  to  a  tablespoonful  of  water  hourly 
or  every  two  hours,  according-  to  the  age  of  the  patient  and  the 
degree  of  fever,  which  doses  may  be  increased,  diminished  or 
discontinued  according  to  the  effect  produced.  With  a  suit- 
able diet  its  tendency  to  excite  nausea  will  not  often  be  mani- 
fested, and  this  may  be  further  counteracted  by  adding-  to  each 
dose  of  the  solution,  when  given,  an  equal  quantity  of  cold 
Vichy  or  seltzer-water  from  a  siphon -bottle. 

If  the  patient  is  robust,  aconite,  in  doses  of  a  fraction  of  a 
drop  of  the  officinal  tincture  every  half  hour  or  oftener  may 
sometimes  be  advantageously  given  for  a  short  time  at  this 
stage  of  the  disease. 

In  case  the  salicylate  of  sodium  is  not  tolerated  or  proves 
ineffective,  antipyrin  or  antifebrin  may  be  resorted  to  if  its 
effect  is  urgently  called  for.  The  former  may  be  given  in 
doses  of  one  and  a  half  grains  for  every  year  of  the  child's  age, 
every  hour  for  three  times,  if  necessary,  and  the  latter  in  one 
fourth  of  these  doses.  I  have  never  found  the  use  of  either  of 
these  drugs  necessary  except  in  diphtheria  complicating  or 
following  scarlatina.  Cold  or  warm  sponging  is  often  a  useful 
and  agreeable  adjuvant.  Quinine  in  antipyretic  doses  is  rarely 
if  ever  appropriate  in  the  early  stage  of  diphtheria. 

In  the  great  majority  of  cases  I  prescribe  from  the  outset 
the  chlorate  of  potassium  and  the  chloride  of  iron. 

The  utility  of  these  drugs  has  been  remarked  upon  on  pages 
191  and  200.  I  have  most  usually  prescribed  them  separately 
and  in  alternation  in  the  following  mixtures,1  which  are  espec- 
ially appropriate  and  pleasant,  and  are  usually  readily  taken 
by  young  Children  : 

No.  1. 
1>     Potassii  chloratis,         .        .        .     3ij. —  3iv. 

Glycerini, fl.  §  ss. 

Aquge  calcis, fl.  §  iijss. 

M.  S. — A  teaspoonful  every  hour. 
1  These  formulae  are  identical  with  those  published  by  me  in  1876. 


220  diphtheria;  its  nature  and  treatment. 

No.  2. 
IJ     Tinct.  ferri  chloridi,  .         .     fl.  3  ij. —  3  iij. 

Glycerini,  .        .        .        .    fl.  3  ij. 

Aquas,         ....       ad.  fl.  §"  iv. 
M.  S. — A  teaspoonful  every  hour. 
Number  two  is  given  in  half-hourly  alternation  with  num- 
ber one.     The  weaker  form  should  generally  be  used  for  chil- 
dren under  three  years  of  age. 

Or  the  two  drugs  may  be  thus  combined : 

No.  3. 
5     Tinct.  ferri  chloridi,  .        .     fl.  3  ij. —  3  iij. 

Potassii  chloratis,      .        .         ,     3ij- — 3iv. 

Glycerini, fl.  §  ij. 

Aquae,         ....      ad.  fl.  3  iv. 
M.    Dose,  a  teaspoonful  every  hour,  or  every  half -hour. 
The  proportion  of  glycerine  in  these  formulae  is  important 
— especially  in  the  treatment  of  children — not  merely  for  its 
demulcent  and  slightly  solvent  action,  but  mainly  for  its  cov- 
ering the  unpleasant  acridity  of  the  tincture  of  iron. 

The  indications  for  discontinuing  or  increasing  the  doses  of 
the  tincture  of  iron  have  been  pointed  out  on  pages  201  and  202. 
"When  it  is  desired  to  increase  them,  this  should  be  done,  in  the 
case  of  children,  not  by  increasing  the  proportion  of  iron  in 
the  mixture,  but  by  giving  larger  quantities  of  the  mixture 
at  a  dose,  and  at  shorter  intervals. 

In  some  cases  the  use  of  the  following  mixture *  at  an  early 
stage  of  the  disease  has  seemed  to  have  a  particularly  good 
effect  in  causing  the  rapid  disappearance  of  membrane  and 
reducing  fever : 

IJ     Acidi  salicylici,      ....    gr.  x. —  3j. 
Sodae  sulphitis,      ....     3  ss. —  3  j. 

Glycerini, fl.  3  ss. 

Aquas, fl.  §  ijss. 

M.  S. — A  teaspoonful  every  hour. 
1  This  formula  was  published  by  me  in  1876. 


TREATMENT.  221 

In  this  solution  the  antiseptic  action  of  the  salicylic  acid  is 
retained.  It  may  be  given  instead  of  number  one  in  half- 
hourly  alternation  with  number  two  or  number  three. 

I  have  used  it  only  during'  the  first  two  or  three  days  of 
the  disease.  Number  one  is  usually  to  be  preferred  in  the  case 
of  young  children. 

The  bichloride  of  mercury  may  be  given  in  connection  with 
the  treatment  already  described.  Its  valuable  effect  is  un- 
doubtedly the  greater  the  earlier  its  use  is  begun.  Its  use  is 
not  indicated  in  mild  cases  of  simple  pharyngeal  diphtheria, 
but  is  appropriate  in  the  early  stage  of  severe  ones,  and  es- 
pecially in  those  in  which  laryngeal  implication  is  threatened, 
either  by  the  symptoms  of  the  patient  or  the  character  of  the 
prevailing  epidemic.  Its  special  utility  and  dangers  and  the  va- 
rious modes  of  administering  it  have  been  referred  to  on  pages 
175-177.  It  should,  under  the  circumstances  now  considered,  be 
given  in  doses  of  from  Tfo  to  -^  of  a  grain,  according  to  age 
and  the  severity  of  the  disease,  hourly,  in  at  least  a  dessert- 
spoonful or  a  tablespoonful  of  water,  milk  or  other  beverage, 
or,  preferably,  in  many  cases,  according  to  the  experience  of 
Dr.  F.  Huber,  in  half  these  doses  half-hourly.  Or,  to  avoid 
the  unnecessary  multiplication  of  doses,  it  may  be  added  to 
formula  number  two  or  number  three,  as  in  the  following  pre- 
scriptions : 

IJ     Hydrargyri  bichloridi,  .     gr.  j2^  — gr.  -£$. 


Or, 


P> 


Tinct.  ferri  chloridi, . 

.    fl.  3  ij. —  3  iij 

Glycerini,  . 

.        .    fl.   iij. 

Aquas, 

ad.  fl.   3  iv. 

M. 

Hydrargyri  bichloridi, 

cry      2          T-p       3 

Tinct.  ferri  chloridi, 

.    fl.  3  ij. —  3  iij. 

Potassii  chloratis,    . 

3iv. 

Glycerini, 

.     fl.   iij. 

Aquas, 

.     ad.  fl.   3  iv. 

M. 

222  diphtheria;   its  nature  and  treatment. 

From  one  one-hundred-and-fiftieth  to  one  one-hundredth  of  a 
grain  of  the  bichloride  is  thus  given  in  each  teaspoonful.  From 
one  to  two  teaspoonfuls  may  be  given  hourly  or  half-hourly. 
It  should  preferably  be  given  after  the  taking  of  food  or  drink. 
It  cannot  be  too  often  repeated  that  its  effect  must  be  care- 
fully watched.  Its  use  should  not  ordinarily  be  continued 
longer  than  three  or  four  days. 

The  strong  evidence  in  favor  of  the  valuable  utility  of  the 
internal  use  of  oil  of  turpentine  has  been  referred  to  (see  page 
194).  That  I  have  never  employed  it  is  due  to  my  aversion  to 
the  use  of  measures  in  the  treatment  of  diphtheria  which  are 
in  themselves  repugnant  to  the  patient,  and  tend  to  produce 
nausea  and  disturbance  of  the  digestive  functions.  Since  it 
need  usually  be  given  only  once  a  day  it  must  be  admitted 
that  this  objection  thereby  loses  much  of  its  force.  Its  special 
applicability  seems  to  be/ like  that  of  mercury,  rather  to  the 
more  superficial  or  "  fibrinous "  rather  than  the  deeper  or 
"  phlegmonous  "  form  of  the  disease,  and  consequently  to  laryn- 
geal rather  than  pharyngeal  diphtheria.  Its  most  valuable 
effect  is  obtained  from  its  early  employment.  The  usual  dose 
is  from  a  teaspoonful  to  a  tablespoonful  in  milk  or  emulsion. 

Various  other  remedies  which  have  been  referred  to  and 
the  manner  of  employing  them  described  on  preceding  pages 
of  this  chapter  may  be  internally  administered  or  locally 
applied  at  this  stage  of  the  disease  with  valuable  effect,  such 
as  the  cyanide  or  the  biniodide  of  mercury  (see  page  17?), 
sulphur,  sulphurous  acid,  the  hyposulphite  of  soda  (pages 
182  and  183),  iodine  (page  185),  iodoform  (page  186),  chloral 
(page  187),  benzoate  of  sodium  (page  190),  peroxide  of  hydro- 
gen (page  188). 

One  or  another  of  these  drags  may  doubtless  in  some  cases 
be  advantageously  substituted  for,  or  used  in  connection  with, 
those  which  have  now  been  especially  recommended;  but  it  is 
important  to  remember  that  the  undue  multiplication  of  rem- 
edies is  particularly  undesirable  in  the  treatment  of  diphtheria, 


TREATMENT.  223 

and  that  from  among-  those  which  promise  equal  efficiency  the 
one  which  is  the  most  pleasant  to  the  taste,  the  most  accepta- 
ble to  the  stomach,  and  the  least  irritating-  in  its  local  effect 
should  always  be  chosen. 

The  diet  in  pharyngeal  diphtheria  should  always  consist  of 
liquids  or  semi-solids.  In  the  early  stage  of  the  disease  it 
should  be  bland  and  simple,  but  nutritious.  Milk  has  been  my 
principal  reliance  in  the  great  majority  of  cases,  especially  of 
children.  It  should  be  given,  if  possible,  in  the  quantity  of 
from  four  to  six  or  eight  ounces  every  two  hours,  but  when 
only  smaller  quantities  can  be  taken  at  once  the  frequency 
with  which  it  is  given  must  be  proportionally  increased.  The 
physician  must  himself  realize,  arid  impress  upon  his  patients 
and  nurses,  that  the  taking-  of  sufficient  nourishment  is  a 
matter  of  prime  and  vital  importance.  It  must  be  insisted 
on,  however  difficult  and  painful  the'  effort  of  swallowing  may 
be.  The  ingenuity  and  perseverance  of  the  physician  and  the 
nurse  must  often  be  exerted  to  the  utmost  degree  to  effect  this 
object.  Even  when  the  act  of  swallowing  is  most  painful  and 
repugnant  to  a  child,  he  can  usually  be  induced  to  take  a  little 
milk  or  other  food  after  each  dose  of  medicine  or  spraying  of 
the  throat  or  syringing  of  the  nose. 

If  milk  is  rejected  by  the  stomach,  the  addition  to  it  of 
lime-water  in  smaller  or  larger  proportions,  up  to  one-half, 
will  often  have  a  good  effect.  It  may  sometimes  be  advanta- 
geously alternated  with  beef,  mutton  or  chicken-tea,  or  oyster 
or  clam-broth.  Though  abundant  nutrition  is  imperatively 
demanded  in  diphtheria,  it  is  a  serious  error  to  overload  the 
stomach  with  rich  or  concentrated  foods  during  the  febrile 
stage  of  the  disease.  In  those  cases  in  which  milk  is  unfort- 
unately not  tolerated,  it  may  sometimes  (though  too  rarely) 
be  made  available  by  peptonizing  it,  or  koumyss  may  be  a 
valuable  resource,  or  the  addition  to  milk  of  a  little  brandy  or 
whiskey  with  or  without  sweetening  may  furnish  the  solution 
to  the  problem.     When  milk  in  no  form  is  tolerated  the  reli- 


224  DIPHTHERIA;     ITS   NATURE   AND   TREATMENT. 

ance  must  be  on  farinacious  gruels,  meat-teas,  juices,  extracts 
and  broths,  beef-peptones,  light  custards,  egg-nog,  etc.,  the 
skill  of  the  nurse  in  such  devices  being  an  important  element 
of  success.  All  other  methods  failing,  nourishment  by  the 
rectum  is  indeed  a  resource — but  a  desperate  one. 

The  use  of  alcoholic  stimulants  is  not  usually  indicated  in 
the  earlier  stage  of  pharyngeal  diphtheria,  except  under  the 
circumstances  and  in  the  manner  just  referred  to.  In  excep- 
tional cases  in  which  the  strength  of  the  patient  has  been  re- 
duced by  previous  illness,  or  in  those  malignant  types  of  the 
disease  in  which  septic  poisoning  with  its  depressing  constitu- 
tional effects  is  evident  from  the  first,  the  indication  for  their 
use  is  obvious  and  imperative. 

In  order  to  economize  to  the  utmost  the  strength  of  the 
patient,  the  administration  of  medicines  and  nourishment, 
which,  in  the  treatment  of  diphtheria,  is  necessarily  frequent, 
should  be  as  systematic  and  reg-ular  as  is  practicable,  and 
should  be  so  arranged  as  to  give  the  patient  the  longest  possi- 
ble intervals  of  rest  between  them.  The  giving  of  medicine, 
the  use  of  the  spray,  and  the  taking  of  nourishment  should  for 
this  reason  usually  come  in  immediate  succession  (though 
sometimes  in  the  opposite  order),  that  the  remainder  of  the 
half-hour  may  be  appropriated  to  rest.  But  the  patient  must 
be  promptly  aroused  at  its  termination,  and  this  punctuality 
and  regularity  must  be  insisted  on,  except  at  night,  when  an 
hour's  undisturbed  sleep  may  in  most  cases  be  occasionally 
permitted.  In  order  to  secure  the  cooperation  of  tender  hearted 
parents  in  this  apparent  cruelty,  it  is  important  to  strongly 
impress  upon  their  minds  its  absolute  necessity. 

The  Treatment  of  Nasal  Diphtheria. 

As  nasal  diphtheria  is  a  very  frequent  complication  of  the 
more  serious  forms  of  the  pharyngeal  affection,  its  treatment 
should  be  considered  before  proceeding  to  that  of  the  later 
stage  of  the  disease. 


TREATMENT.  225 

From  the  special  danger  of  septic  infection  which  attends 
this  form  of  diphtheria,  results  the  imperative  indication  of 
the  cleansing*  and  disinfection  of  the  nasal  passages.  It  is 
essential  that  the  physician  realize  that  this  is  to  be  effected, 
not  by  the  introduction  into  them  of  a  little  mildly  antiseptic 
fluid,  but  by  the  most  thorough  removal  from  them  of  their 
poisonous  contents  which  is  practicable.  It  is  also  highly  im- 
portant that  this  be  accomplished  with  the  least  possible  irri- 
tation, annoyance  or  fatigue. 

The  instruments  which  may  be  employed  for  the  purpose 
are  the  syringe  or  douche  or  the  nasal  atomizer.  The  use  of 
the  latter  requires  for  its  efficiency  a  coarse  spray  forcibly 
driven,  the  effect  of  which,  in  the  treatment  of  diphtheria,  is 
at  once  more  irritating-  and  less  thorough  than  that  of  a 
stream  from  a  syringe  properly  used. 

The  syringing  of  the  nares  is  necessarily  somewhat  un- 
pleasant to  the  patient,  and  usually  provokes  the  violent  re- 
sistance of  young  children.  When  bunglingly  performed  it 
may  be  most  distressing,  ineffective  and  injurious. 

The  struggles  of  young  children  and  the  consequent  danger 
of  exhaustion  and  injury  are  best  prevented  by  the  well  di- 
rected use  of  overmastering  force  combined  with  manual  dex- 
terity and  gentleness.  Much  experience  has  taught  me  the 
advantages  of  the  following  method : 

The  assistance  of  two  persons  is  required.  The  child  is 
seated  across  the  lap  of  one  of  these  persons,  who  secures  his 
hands  with  one  of  her  own,  and  with  the  other  holds  a  basin 
to  receive  the  discharge.  The  other  person  stands  behind  the 
child,  takes  his  head  between  the  palms  of  her  hands,  and, 
leaning  forward,  holds  it  firmly  against  her  breast.  A  third 
person  who  should,  when  possible,  be  a  physician,  can  then 
easily  make  the  injection  into  the  child's  nostrils  without  dan- 
ger of  injury  to  them  by  its  sudden  movements. 

When  the  child  is  thus  firmly  held,  or  in  the  case  of  older 

patients,  any  small  syringe  will  answer  in  careful  and  skilful 
15 


226  diphtheria;  its  nature  and  treatment. 

hands;  but  under  other  circumstances  one  should  be  used 
which  has  a  blunt  and  soft  tip.  It  should  also  have  a  ring"  in 
the  handle,  that  it  may  be  conveniently  manipulated  by  one 


Fig.  13.— Manner  of  Holding  a  Child  for  Nasal  Syringing. 

hand.  The  hard  rubber  half-ounce  ear-syringe  is  in  most  re- 
spects a  very  suitable  instrument;  but  its  tip  should  either  be 
cut  off,  as  Avas  suggested  by  Dr.  S.  W.  Smith,1  or,  still  better, 
should  be  padded, — a  device  which  was  recommended  by  Bre- 
1  New  York  Medical  Record,  1886,  29,  p.  354. 


TREATMENT. 


227 


tonneau.1  This  is  easily  clone  by  surrounding  it  with  absorb- 
ent or  other  cotton  and  fastening-  over  this  a  perforated  piece 
of  rubber-cloth,  oiled  silk,  chamois-leather  or  muslin,  as  is 


Fig.  14.— Hard  Rubber  Half-Ounce  Ear-Syringe.     (Reduced  Size.) 
I 


Fig.  15. — Ear-Syringe  Padded. 


shown  in  figure  16.     As  this  requires  but  a  moment,  the  pad- 
ding- may  be  changed  after  each  syringing. 

A  glass  syringe  expressly  designed  for  this  purpose,  the 


Fig.  16. — Peerless  Syringe,  No.  4. 


nozzle  of  which  is  protected  by  a  covering  of  soft  rubber,  is 
manufactured  by  R.  Van  der  Emde,  323  Bowery,  New  York, 

and  is  called  "  Peerless  Syringe,  No.  4." 


Fig.  17.— Universal  Syringe. 


An  instrument  which  will  serve  very  well  in  most  cases  is 
the  "universal  syring'e"  made  by  Tiemann  &  Co.,  which  is  en- 
tirely of  soft  rubber. 


1  Fifth  Memoir. 


228  diphtheria;  its  nature  and  treatment. 

Warm  salt-water  (one  drachm  to  the  pint)  is  admirably 
suited  to  the  purpose.  The  addition  to  it  of  bichloride  of  mer- 
cury (one  grain  to  the  pint)  or  of  borax  (one  or  two  drachms 
to  the  pint)  or  of  salicylic  acid  (four  grains  to  the  pint)  is  re- 
garded as  an  improvement  by  some. 

The  fluid  should  be  thrown  with  force  enough  to  make  it 
flow  out,  partly  by  the  other  nostril  and  partly  by  the  throat, 
if  the  passages  are  pervious.  If  they  are  not  so,  more  forcible 
injections  may  be  employed,  and  these,  with  a  little  persever- 
ance, will  usually  succeed.  Undesirable  as  these  may  seem, 
the  removal  of  the  obstructing  mass  should  be  regarded  as 
imperative.  Tearing  away  or  boring  through  the  membrane 
should  not  be  resorted  to  on  account  of  the  great  danger  of 
its  causing  epistaxis.  The  very  frequent  application  of  pepsin, 
trypsin  or  papayotin  by  means  of  a  medicine-dropper  may  be 
of  service  in  very  obstinate  cases. 

The  injections  should  be  repeated  on  each  occasion  until  the 
passages  are  thoroughly  cleansed.  From  two  or  three  to  five 
or  six  applications  to  each  nostril  are  usually  sufficient  to  ac- 
complish this. 

When  the  operation  is  thus  thoroughly  performed,  I  have 
found  by  experience  in  many  cases  that  its  repetition  from 
two  to  four  times  in  the  twenty-four  hours  is  usually  sufficient 
to  secure  the  desired  effect.  Its  repetition  with  unnecessary 
frequency  is  to  be  deprecated,  since  it  is  more  or  less  unpleas- 
ant and  irritating  and  consequently  fatiguing,  even  to  adults, 
from  the  especial  susceptibility  of  the  nasal  mucous  mem- 
brane, and  much  more  so  to  children  who  have  to  be  coerced, 
and  in  the  treatment  of  bad  cases  of  this  disease  the  strength 
cannot  be  too  carefully  economized.  When  it  is  only  partially 
or  imperfectly  done,  as  it  must  be  by  only  a  single  injection 
into  each  nostril  on  each  occasion,  as  is  practiced  by  some,  it 
of  course  becomes  necessary  much  oftener. 

When  the  syringing  of  the  nares  has  to  be  entrusted  to 
nurses,  they  must  be  carefully  instructed  by  the  physician  as 


TREATMENT.  229 

to  all  its  details,  such  as  the  angle  (more  nearly  horizontal  than 
perpendicular)  at  which  the  syringe  is  to  be  introduced,  etc., 
and  even  then  he  will  too  often  have  the  pain  of  finding-  that 
it  has  been  very  imperfectly  or  badly  executed. 

I  have  dwelt  at  such  length  on  the  details  of  nasal  syring- 
ing, because,  whatever  may  be  thought  of  the  utility  of  vari- 
ous other  therapeutical  measures  in  the  treatment  of  diph- 
theria, there  can  be  no  doubt  that  upon  this  one  the  saving  of 
many  hundreds  of  lives  every  year  directly  depends.  If  it  is 
neglected  in  severe  cases  of  nasal  diphtheria  the  patient  is 
almost  sure  to  die;  if  it  is  efficiently  performed  the  greater 
proportion  recover. 

The  Treatment  of  the  Later  Stage  of  Pharyngeal  and 
Nasal  Diphtheria. 

The  special  indications  for  treatment  in  the  later  stage  of 
diphtheria  are : 

1.  To  continue  local  measures  for  antiseptic  effect. 

2.  To  counteract  the  effects  of  constitutional  poisoning. 

3.  To  sustain  the  strength  of  the  patient. 

4.  To  appropriately  deal  with  complications  which  may 
arise. 

In  a  large  majority  of  all  cases  which  have  been  treated 
early  and  efficiently  by  the  methods  already  described,  the 
disease  will  have  been  so  favorably  modified  by  them,  in  limit- 
ing the  extension  and  moderating  the  intensity  of  the  local 
affection  and  preventing  or  minimizing  the  absorption  of 
poison,  that  they  may  be  without  difficulty  conducted  to  com- 
plete recovery,  after  a  duration  of  from  four  to  twelve  days, 
by  the  continuance  of  the  mild  solvent  and  antiseptic  local 
treatment,  the  internal  administration  of  chloride  of  iron  and 
the  chlorate  of  potash  and  the  measures  for  nutrition  and 
rest  which  have  been  recommended. 

In   a  much  smaller  proportion  of  cases,  which,  however, 


230  DIPHTHERIA;     ITS   NATURE   AND   TREATMENT. 

varies  considerably  in  different  epidemics,  in  which  the  disease 
is  from  the  outset  of  especial  severity  or  malignancy,  and  of 
the  deeply  infiltrated  or  "  phlegmonous-septic "  type,  and  in 
other  cases  in  which  treatment  is  begun  only  at  an  advanced 
stage  of  the  malady,  an  arduous  and  prolonged  conflict  with 
it  is  yet  to  be  waged. 

At  this  stage  in  such  cases,  hyperpyrexia  has  usually  dis- 
appeared along  with  the  acute  intensity  and  tendency  to  rapid 
extension  of  the  local  inflammation,  and  evidences  of  constitu- 
tional or  septic  poisoning  present  themselves. 

It  is  of  the  utmost  importance  that  the  physician  realize 
that  his  chief  resource  in  order  to  prevent  the  system  being 
fatally  overwhelmed  by  this  poison  is  in  diminishing  the  amount 
introduced  into  the  circulation  by  the  most  thorough  possible 
cleansing  of  the  sources  from  which  it  is  absorbed. 

The  means  for  effecting  this  object,  namely,  washing  them 
with  suitable  antiseptic  solutions,  applied  by  internal  admin- 
istration, spraying  and  irrigation,  have  already  been  described. 
If  they  are  neglected  or  only  inefficiently  employed,  it  will  too 
often  be  found  that  no  amount  of  stimulation  or  other  internal 
medication  will  avail  to  save  the  patient. 

I  have  in  many  instances,  after  beginning  the  treatment  of 
a  case  at  this  stage  of  the  disease,  seen  the  pallor  and  sallow- 
ness  of  the  skin  soon  replaced  by  natural  tints,  apathy  and 
somnolence  disappear,  nausea  and  vomiting  cease,  the  dull 
eye  become  bright,  the  feeble  and  flickering  pulse  become  full 
and  regular,  simply  or  mainly  from  the  effect  of  these  meas- 
ures. In  some  of  them  heroic  stimulation  and  medication, 
previously  employed  under  other  direction,  had  failed  to  pro- 
duce an}r  favorable  effect. 

This  good  effect  is  often  manifested  in  spite  of  the  persist- 
ent presence  of  quite  extensive  membranous  deposits.  In  this 
case  the  effect  of  the  antiseptic  washes  is  doubtless  exerted 
not  only  by  their  removing  from  all  the  surfaces  much  poison- 
ous material  which  would  otherwise  be  absorbed,  but  also  by 


TREATMENT.  231 

their  penetrating"  in  some  degree  the  false  membrane  itself, 
and  thus  causing,  by  osmotic  action  and  the  interchange  of 
fluids,  more  or  less  diminution,  dilution  and  disinfection  of  the 
noxious  products  of  the  disease  lying  beneath  it. 

The  denser  and  thicker  the  false  membrane  is,  the  less,  of- 
course,  can  the  latter  effect  be  produced.  Hence  the  difficul- 
ties in  the  way  of  thorough  local  disinfection  are  often  very 
great  and  sometimes  insuperable,  especially  in  the  cases  of 
young  children.  When  masses  of  thick  membrane  oppose  it, 
these  may,  if  accessible,  be  softened  and  thinned  by  the  fre- 
quent application  of  the  solvents  which  have  been  referred  to, 
or  in  some  cases  by  the  careful  application  of  such  agents  as 
MonseFs  solution,  which  tend  to  shrivel  and  disintegrate  them 
and  restore  tone  to  the  relaxed  and  infiltrated  tissues. 

Adenitis,  in  such  cases,  often  presents  a  serious  obstacle  to 
antiseptic  endeavors,  since  the  diphtheritically  inflamed  glands 
are  in  themselves  inaccessible  foci  of  infection.  In  the  treat- 
ment of  this  complication,  it  must  still  be  remembered  that 
the  first  indication  is  by  the  local  antiseptic  measures  just  re- 
ferred to,  to  prevent  or  limit  the  absorption  of  more  poison 
through  the  lymphatics  into  the  glands.  The  adenitis  itself 
may  be  let  alone  or  treated  with  cold  or  warm  applications. 
If  there  is  febrile  temperature  and  the  adenitis  is  increasing, 
ice-bags  may  be  applied.  If  the  adenitis  is  no  longer  increas- 
ing and  is  not  especially  annoying,  it  is  best  let  alone.  If, 
in  the  later  stage  of  the  disease,  the  tumors  are  large  and 
painful  or  show  a  tendency  to  suppuration,  they  should  be 
treated  with  warm  poultices.  The  application  of  ointments 
of  iodine  or  iodoform  or  mercury  is  probably  useless.  All  irri- 
tant applications  to  the  skin  should  be  avoided.  The  applica- 
tion of  the  linimentum  belladonna?,  mixed  with  half  the  quan- 
tity of  glycerine,  has  in  some  cases  seemed  to  me  to  have  a 
soothing  and  beneficial  effect. 

The  second  and  third  indications  above  referred  to,  though 
distinct,  are  yet  to  be  mainly  fulfilled  by  the  same  means, 


232  diphtheria;  its  nature  and  treatment. 

namely,  the  chloride  of  iron,  abundant  nourishment,  alcoholic 
stimulants  and  appropriate  tonics. 

The  pre-eminent  utility  of  the  chloride  of  iron  in  enabling' 
the  system  to  withstand  the  effects  of  diphtheritic  poisoning- 
has  been  remarked  upon  on  page  200.  When  this  condition  is 
present  it  must  be  freely  administered.  Formula  number  two 
(page  220)  should  be  used,  and  of  this  mixture  from  one  to  two 
teaspoonfuls  may  be  given  every  half-hour,  according  to  age 
and  tolerance,  or  in  very  urgent  cases,  every  twenty  minutes. 

The  maintenance  of  abundant  nutrition  is  of  primary  im- 
portance. Not  only  is  this  essential  for  sustaining  the  strength, 
but  it  is  practically  an  antiseptic  measure,  since  the  less  is  the 
suppty  of  nourishment  to  the  system,  the  greater  is  the  ab- 
sorption of  poison.  If  milk  is  freely  taken  it  is  still  the  most 
suitable  food,  but,  in  view  of  the  tendency  to  the  failure  of 
strength,  more  stimulating  articles  may  often  be  advanta- 
geously added  to  the  dietary.  Among  the  most  useful  of 
these  is  the  freshly  expressed  juice  of  underdone  beef  in  small 
quantities,  or  Valentine's  beef-juice.  Concentrated  and  pre- 
digested  food-preparations,  such  as  the  various  "beef-pep- 
tones," "liquid  peptonoids,"  etc.,  may  often  be  serviceable. 
Other  suitable  additions  to  the  dietary  have  been  already  re- 
ferred to  (page  223).  Discretion  in  the  administering  of  rich 
or  concentrated  foods  is,  however,  very  important,  since  the 
digestive  function  too  often  shares  in  the  general  enfeeble- 
ment,  and  may  be  easily  deranged.  Excessive  or  injudicious 
feeding  may  thus  defeat  the  very  object  for  which  it  is  em- 
ployed. 

Alcoholic  stimulants  are  required  in  most  bad  cases  at  this 
stage  of  the  disease,  and  must  in  many  cases  be  given  freely. 
Their  utility  in  the  treatment  of  diphtheria,  and  its  limitations, 
have  been  remarked  upon  on  page  203  et  seq. 

Valuable  assistance  in  promoting  appetite  and  digestion 
and  combatting  the  tendency  to  debility  which  attends  the 
later  stage  of  diphtheria  and  the  period  of  convalescence,  may 


TREATMENT.  233 

be  obtained  from  various  tonics,  especially  the  preparations 
and  alkaloids  of  cinchona  bark  and  mix  vomica.  Among 
standard  preparations,  the  compound  tincture  of  cinchona  or 
the  elixir  or  wine  of  calisaya,  the  elixir  of  pepsin,  bismuth  and 
strychnine,  the  elixir  of  the  phosphates  of  iron,  quinine  and 
strychnine  given  in  doses  appropriate  to  the  age,  have  obvious 
applications  and  utilities  in  this  as  in  other  diseases.  The 
same  in  true  of  quinine  in  tonic  doses  of  from  one  fourth  of  a 
grain  to  two  grains  three  or  four  times  a  day.  I  have  been 
enabled  to  obviate  the  important  difficulty  arising  from  its 
unpleasant  bitterness  in  many  cases  of  young  children  by  the 
use  of  chocolate  lozenges,  each  of  which  contains  one  grain  of 
the  tannate  of  quinine,  and  which  are  prepared  by  Caswell 
and  Massey  of  this  city.  They  are  generally  liked  by  children. 
Quinine  may  also  in  many  cases  be  advantageously  adminis- 
tered to  young  children  in  rectal  suppositories.  Two  or  three 
grains  of  the  sulphate  of  quinine  in  five  or  six  grains  of  the 
butter  of  cacao  in  each  suppository  is  a  convenient  size.  Their 
introduction  is  facilitated  by  the  use  of  a  small  hard-rubber 
tube-and-piston  depositor  which  is  made  for  the  purpose. 

In  conditions  of  extreme  debility  with  accompanying  pro- 
gressive heart-failure,  alcoholic  stimulants  given  freely,  but 
with  careful  regard  to  the  limit  of  their  tolerance  by  the  stom- 
ach, are  our  most  valuable  resource.  If  the  pulse  is  feeble  and 
rapid  or  irregular,  the  tincture  of  digitalis  may  be  given  in 
small  doses,  the  effect  of  which  is  to  be  carefully  watched,  and 
strychnine  in  small  doses  (from  -^  to  3V  of  a  grain)  may  be 
useful.  Except  in  the  case  of  very  sensitive  children,  to  whom 
the  shock  and  fright  caused  by  the  operation  may  be  injurious, 
the  hypodermic  administration  of  either  of  these  remedies  is 
to  be  preferred  on  account  of  its  more  prompt  and  certain 
effect.  Freshly  made  coffee  in  teaspoonful  doses  may  also  be 
serviceable.  Fresh  beef-juice  in  similar  doses  may  have  a  val- 
uable stimulant  effect.  The  predigested  foods  already  referred 
to  may  be  useful  aids  in  maintaining  nutrition.     The  great 


234  diphtheria;  its  nature  and  treatment. 

importance  of  the  most  abundant  supply  of  fresh  air  should 
never  be  forgotten.  If  such  bulky  and  unpleasant  drugs  as 
musk  are  employed  in  the  case  of  children,  their  administra- 
tion by  enema  is  for  obvious  reasons  to  be  preferred.  The 
patient  must  be  strictly  kept  in  the  recumbent  posture  and 
all  unnecessary  exertion  and  agitation  avoided. 

The  mere  fact  of  the  occurrence  of  albuminuria  does  not 
ordinarily  call  for  special  treatment.  Indeed,  since  its  pres- 
ence at  this  stage  is  usually  the  result  of  the  irritation  of  the 
kidneys  by  the  noxious  products  of  the  disease  which  have 
been  absorbed  into  the  general  circulation;  the  indication  which 
it  furnishes  is  the  continuance  of  the  antiseptic  and  sustaining 
measures  which  have  been  already  referred  to. 

The  same  indication  remains  equally  in  force  in  those 
graver  forms  of  the  affection  in  which  the  urine  more  or  less 
suddenly  becomes  scanty  and  dark  and  of  high  specific  gravity, 
and  contains  a  large  percentage  of  albumin  with  casts  and 
blood-corpuscles,  with  accompanying  febrile  symptoms  and 
marked  evidences  of  ursemic  poisoning;  but  the  complication 
itself  is  so  liable  to  be  rapidly  fatal,  that  prompt  measures 
must  be  employed  for  its  removal.  These  measures  are  the 
same  as  when  nephritis  occurs  in  other  conditions,  but  the 
weakness  and  prostration  of  the  patient  often  make  their 
energetic  employment  impracticable.  In  cases  in  which  this 
weakness  and  prostration  are  not  too  marked  for  its  use  to  be 
admissible,  and  especially  if  the  bowels  are  constipated,  purga- 
tion by  a  single  dose  of  from  one  to  five  grains  of  calomel  or 
by  doses  of  a  quarter  of  a  grain  given  in  frequent  succession 
or  by  a  grain  of  calomel  with  from  six  to  ten  grains  of  com- 
pound jalap  powder  to  a  child  from  three  to  five  years  old,  or 
to  feebler  patients  a  wine-glassful  of  citrate  of  magnesia  re- 
peated every  hour  or  two  if  necessary,  will  often  have  a 
promptly  favorable  effect. 

Dry  cups  may  be  applied  over  the  kidneys. 

The  mode  of  producing  at  once  a  revulsive  and  diaphoretic 


TREATMENT.  235 

effect  which  I  have  found  especially  valuable  in  many  cases  of 
scarlatinal  and  diphtherial  nephritis  is  to  envelop  the  entire 
circumference  of  the  loins  and  abdomen  with  a  warm  flax-seed 
poultice,  which  should  be  frequently  renewed. 

The  use  of  the  ordinary  diaphoretic  and  diuretic  drugs  is 
often  impracticable  on  account  of  the  tendency  to  nausea  and 
vomiting-  and  the  weakness  of  the  patient.  Digitalis  may  be 
given  in  the  form  of  the  infusion  with  citrate  or  acetate  of 
potash  if  the  stomach  will  retain  it;  but  otherwise  in  the  form 
of  the  tincture,  of  which  a  suitable  dose  may  be  added  to  other 
medicines  or  administered  hypodermically. 

Throughout  the  entire  treatment  of  a  case  of  diphtheria, 
great  importance  should  be  attached  to  maintaining  the  strict- 
est cleanliness  of  the  patient  himself  and  all  his  surroundings. 
His  clothing  and  the  bed-linen  should  be  frequently  changed 
and  thorough  disinfection  of  all  vessels  and  utensils  practiced, 
as  directed  in  the  chapter  on  prophylaxis.  The  room  should 
be  frequently  and  thoroughly  aired.  In  order  that  the  patient 
may  not  take  cold  while  this  is  being  done  the  alternate  use 
of  two  adjoining  rooms,  when  practicable,  is  an  advantage  in 
the  colder  season  of  the  year.  In  some  persistent  cases  the 
removal  of  the  patient  to  a  fresh  apartment  has  seemed  to 
exert  a  favorable  influence.  When  the  climate  and  other  cir- 
cumstances make  it  practicable,  the  patient  may  sometimes 
be  advantageously  kept  in  the  open  air. 

The  Treatment  of  Laryngeal  Diphtheria. 

Medical  Treatment  in  reference  to  laryngeal  diphtheria  is 
(1)  preventive  and  (2)  mitigating  or  curative. 

The  liability  of  pharyngeal  and  nasal  diphtheria  to  extend 
downward  into  the  larynx,  especially  during  the  first  few 
days,  suggests  the  employment  of  measures  in  their  early 
stage  which  may  diminish  that  liability.    These  measures  are : 

1.  Those  which  tend  to  moderate  the  intensity  and  check 
the  spread  of  the  primary  affection,  since  that  result  diminishes 


236  DIPHTHERIA;     ITS   NATURE   AND   TREATMENT. 

the  probability  of  its  extension  into  the  larynx.     These  meas- 
ures have  already  been  referred  to. 

In  the  treatment  of  young-  children  all  irritating-  applica- 
tions and  unpleasant  remedies  which  cause  crying  and  strug- 
gling are  especially  contra-indicated,  since  in  such  crying  and 
struggling  the  irritating  drug  or  diphtheritic  matter  is  liable 
to  be  drawn  into  the  larynx  and  favor  the  extension  of  the 
disease  thither. 

2.  Those  which  have  a  special  tendency  to  prevent  laryn- 
geal implication. — These  measures  are  the  inhalation  of  un- 
irritating  antiseptic  and  astringent  spray  or  vapor  and  also 
the  internal  use  of  certain  drugs,  especially  mercurials  and  the 
oil  of  turpentine.  These  have  also  been  referred  to  in  connec- 
tion with  the  treatment  of  pharyngeal  diphtheria. 

My  own  experience  of  the  valuable  effect  of  this  use  of  the 
spray  of  carbolic  acid  and  lime-water  was  stated  in  my  first 
published  report  as  follows :  "  Out  of  fully  one  hundred  cases, 
including  Dr.  Darken's,  in  which  the  spray  of  carbolic  acid  and 
lime-water  has  been  employed,  there  has  been  no  instance  of 
the  subsequent  occurrence  of  serious  laryngeal  complication, 
though  in  several  of  them  it  has  been  threatened  by  croupy 
cough,  hoarseness  and  aphonia.  That  the  inhalation  of  the 
spray  has  acted  as  a  preventive  in  some  of  these  is,  I  think, 
not  improbable."  Much  subsequent  experience  of  myself  and 
others  has  confirmed  me  in  this  belief.  The  composition  of  this 
spray  and  the  mode  of  using  it  have  been  stated  on  page  215. 

In  the  case  of  children  too  young  to  take  the  spray,  the  in- 
halation of  antiseptic  vapor,  especially  that  of  the  oil  of  tur- 
pentine,  may  be  employed  as  a  preventive. 

Mitigating  and  Curative  Measures. — The  earliest  possible 
recognition  and  treatment  of  laryngeal  diphtheria  is  of  great 
importance.  The  physician  should  pay  careful  attention  to 
the  slightest  huskiness  or  hoarseness  of  the  voice  which  may 
be  its  premonitory  symptom.  Many  cases  may  doubtless  be 
cut  short  or  prevented  from  becoming  severe  when  properly 


TREATMENT.  237 

treated  at  their  first  slight  beginning's,  which  would  later 
defy  all  remedies. 

When  the  symptoms  of  laryngeal  diphtheria  are  present 
the  measures  to  be  employed  depend  somewhat  upon  their 
gravity  and  the  rapidity  with  which  they  increase.  In  esti- 
mating at  the  outset  the  probability  of  their  becoming  severe, 
the  fact  elsewhere  referred  to  may  be  remembered,  that  as  a 
general  (though  not  invariable)  rule  this  probability  is  greater 
the  earlier  the  laryngeal  affection  appears. 

The  remedies  which  may  be  employed  comprise  mercurials, 
solvent,  antiseptic  and  astringent  sprays  and  vapors,  steam, 
expectorants  and  emetics. 

The  mildly  solvent  and  antiphlogistic  effect  of  the  pleasant 
spray  of  carbolic  acid  and  lime-water  has  been  found  sufficient 
in  quite  a  number  of  cases  of  slight  or  moderate  severity.  In 
my  first  paper 1  I  reported  in  detail  a  case  of  unquestionable 
laryngeal  diphtheria  accompanying  pharyngeal  diphtheria  in 
a  child  of  four  years,  in  which  very  serious  and  constant 
dyspnoea  in  both  acts,  with  marked  depression  over  the  clavi- 
cles with  inspiration,  continued  for  eleven  days,  but  which 
finally  recovered  without  operation  under  the  very  frequent 
use  of  this  spray.  I  have  since  seen  several  almost  as  striking 
cases  of  recovery  under  the  use  of  the  same  remedy. 

The  fact  has  been  referred  to  that  the  solvent  power  of 
lime-water  may  be  increased  by  adding  to  it  another  alkali, 
as,  for  instance,  one  per  cent,  of  liquor  potassa?,  or  bicarbonate 
of  soda,  but  at  the  expense  of  making  its  frequent  and  contin- 
ued use  somewhat  irritating  to  mucous  membranes.  Hence 
this  method  should  be  employed  only  where  the  necessity  for 
a  rapid  solvent  effect  is  urgent. 

The  testimony  in  favor  of  the  utility  of  trypsin  and  papay- 
otin as  solvents  of  false  membrane  has  been  referred  to,  and 
the  manner  of  employing  them  has  been  described  on  pages 
168  and  169.  The  solution  should  be  carefully  prepared  by 
transactions  of  N.  Y.  Academy  of  Medicine,  1876,  p.  210. 


238  DIPHTHERIA;    ITS   NATURE   AND    TREATMENT. 

rubbing-  the  solvent  in  a  mortar  and,  if  necessary,  afterward 
straining-  it,  so  that  a  fine  spray  may  be  used,  and  the  solu- 
tion should  be  of  the  most  unirritating  character,  so  as  not 
to  excite  cough  and  dyspnoea. 

It  must  be  remembered  that  the  spray  can  effectively 
reach  the  interior  of  the  larynx  only  by  being  carried  thither 
by  the  inspired  air.  The  atomizer  should  therefore  be  held 
at  some  little  distance  from  the  mouth  (which  must  be 
widely  opened  and  the  tongue  depressed  if  necessary)  so 
that  the  atomized  particles,  having  lost  their  first  impetus, 
may  be  carried  downward  in  the  current  of  the  breath.  This 
necessitates  some  moistening  of  the  face  with  the  spray,  but 
even  quite  young  children,  with  proper  management,  soon 
become  accustomed  to  it  and  tolerate  it. 

The  same  principle  is  applied  in  instruments  called  "  nebu- 
lizers," or  "  vaporizing  atomizers,"  which  have  recently  been 
brought  into  use,  by  which  the  particles  are  so  suspended  in 
the  air  as  to  be  readily  carried  into  the  air-passages  by  the 
breath.  Liquids,  in  order  to  be  "  nebulized,"  require  to  be  given 
a  certain  consistency  by  the  addition  of  not  less  than  one- 
eighth  part  of  glycerine,  or  some  similar  substance.  In  the 
limited  opportunities  which  I  have  as  yet  had  for  experiment- 
ing with  these  instruments  I  have  not  been  able  to  satisfy 
myself  that  the  amount  of  medicated  fluid  which  can  be  so  in- 
troduced is  sufficient  to  be  effective  in  the  treatment  of  croup, 
but  I  think  it  not  improbable  that  they  may  be  found  to  have 
some  utility.  One  of  the  best  of  them  is  the  "vaporizing 
atomizer,  No.  169,"  made  by  Codman  and  Shurtleff. 

Though  the  use  of  the  hand -atomizer  has  obvious  advanta- 
ges in  point  of  convenience,  yet  in  most  cases  in  which  it  is 
practicable  the  application  of  spray  together  with  warm 
vapor,  by  means  of  the  steam-atomizer,  is  to  be  preferred. 

Unfortunately,  the  impracticability  of  applying  spray  to 
very  young  children  precludes  its  employment  in  a  considera- 
ble proportion  of  our  worst  cases.     The  evils  attending  its  ap- 


TREATMENT. 


239 


plication  by  force  more  than  counterbalance  its  benefits.  I 
have  made  many  attempts  to  overcome  this  difficulty  by  vari- 
ous expedients,  but  never  with  satisfactory  results. 

In  cases  in  which  the  efficient  use  of  spray  is  impracticable, 


Fig.  18.— Vaporizing  Atomizer. 


and  in  most  cases  whicli  are  serious  or  show  a  tendency  to 
become  so,  the  inhalation  of  steam  should  be  resorted  to.  The 
most  efficient  method  of  doing-  this  is  the  construction  of  a 
tent  over  the  crib  or  bed  with  blankets  and  barrel-hoops  or 


Fig.  19.— Steam  Atomizer. 


other  supports.  There  should  be  an  opening-  in  one  side  of  the 
tent  for  ventilation.  The  air  within  the  tent  may  be  kept 
saturated  with  warm  vapor  by  means  of  a  tube  from  a  croup- 
kettle,  which  should  be  placed  outside  of  it. 


240  diphtheria;  its  nature  and  treatment. 

The  air  in  the  tent  being-  thus  maintained  at  an  equable 
warmth,  and  draughts  being  excluded,  the  room  can  safely  be 
ventilated  by  opening  the  window  or  otherwise,  and  the  evil 
effect  of  the  impairment  of  the  air  by  the  burning  of  the  alco- 
hol or  other  combustible  employed,  be  in  great  measure  ob- 
viated. 

In  the  absence  of  a  croup-kettle,  an  ordinary  tea-kettle  and 
a  gas  or  oil-stove  may  be  made  to  answer  the  purpose.    When 


Fiq.  20.— Croup-kettle. 

india-rubber  tubing  cannot  be  obtained,  a  substitute  may  be 
made  with  stiff  paper  or  pasteboard  surrounded  with  some 
fabric,  as  a  roller-bandage. 

Or  a  small  room  in  which  boiling  water  can  be  kept  con- 
stantly running  from  the  pipes,  or  in  which  steam-pipes  can 
be  tapped,  may  be  utilized. 

The  solvent  effect  of  lime  on  the  false  membrane  may  be 
additionally  obtained  by  putting  pieces  of  quick-lime  into 
the  water  in  the  croup-kettle  every  hour  or  two.     It  should 


TREATMENT.  2<±1 

always  be  remembered  that  the  boiling-  of  lime-water  for  this 
purpose,  which  is  often  recommended,  is  useless. 

The  vapor  may  be  made  the  vehicle  of  various  drugs  for 
their  antiseptic  or  specific  effect.  The  most  valuable  of  these 
is  the  oil  of  turpentine.  This  may  be  added,  a  tablespoonful 
at  a  time,  to  the  water  in  the  croup-kettle,  every  hour  or  two, 
or  it  may  be  volatilized  in  the  air  of  the  room  by  the  method 
of  Dr.  Delthil,  described  on  page  197.  Its  good  effect  may 
perhaps  be  aided  by  adding  a  teaspoonful  or  two  of  the  oil  of 
eucalyptus. 

The  abundant  evidence  of  the  special  utility  of  the  bi- 
chloride of  mercury  in  the  treatment  of  this  form  of  diphtheria, 
and  the  importance  of  its  early  employment,  have  been  already 
referred  to.  When  the  drug  is  given  to  avert  threatened 
laryngeal  stenosis,  the  indication  is,  of  course,  to  bring  the 
system  of  the  patient  as  rapidly  under  its  influence  as  is  con- 
sistent with  safety.  In  such  circumstances  it  is  important  to 
know  that  the  tolerance  of  it  is,  in  many  children,  remarkably 
great.  Dr.  Jacobi  states  *  that  "  a  baby  a  year  old  may  take 
one-half  grain  every  day  many  days  in  succession  with  very 
little  if  any  intestinal  disorder  and  with  no  stomatitis,"  if  it 
be  given  in  proper  dilution.  This  is  equivalent  to  one  forty- 
eighth  of  a  grain  every  hour.  Dr.  O'Dwyer,  who  has  employed 
this  remedy  in  many  cases  of  croup,  and  regards  it  as  very 
valuable,  begins  with  about  one  eightieth  of  a  grain  at  that 
age,  and  gradually  increases  to  the  dose  mentioned  by  Dr. 
Jacobi,  if  the  case  threatens  to  run  a  rapid  course.  He  very 
seldom  begins  at  any  age  with  more  than  one  fiftieth  of  a 
grain  hourly,  and  increases  or  not  according  to  the  progress 
of  the  case.  He  also  attaches  much  importance  to  proper 
dilution,  having  known  one  fiftieth  of  a  grain  dissolved  in  two 
drachms  of  water  to  give  rise  to  severe  pains  in  the  stomach, 
which  did  not  recur  when  the  dilution  was  increased  to  half 
an  ounce.     He  has  yet  to  see  any  serious  gastric  or  intestinal 

1  Loc.  cit. 
16 


242  diphtheria;  its  nature  and  treatment. 

disturbance,  or  more  than  the  slightest  amount  of  stomatitis, 
from  the  sublimate  administered  in  this  manner,  even  when 
continued  so  long-  as  a  week.  A  moderate  looseness  of  the 
bowels  is,  according'  to  his  experience,  easily  controlled  by  the 
addition  of  a  mild  opiate,  but  directions  should  always  be  left 
with  the  attendant  to  suspend  the  medicine  on  the  occurrence 
of  any  severe  diarrhoea  or  much  pain  in  the  stomach  or  bowels. 

The  advantage,  when  large  doses  are  being  administered, 
of  giving  them  in  half  the  quantity  every  half -hour,  has  been 
referred  to  on  page  221. 

The  administration  of  mercury  by  inunction,  by  hypodermic 
injection,  and  by  volatilization  and  inhalation,  has  been  re- 
ferred to  on  pages  177,  and  178. 

The  internal  administration  of  the  oil  of  turpentine  has 
also  been  referred  to  on  pages  195  and  222. 

Emetics  have  a  well  established  utility  in  the  treatment  of 
croup,  whether  catarrhal  or  diphtheritic;  but  they  should  be 
used  with  discretion — not  too  often,  nor  usually  in  the  later 
stages  of  the  disease,  nor  ever  in  conditions  of  marked  weak- 
ness, systemic  infection  or  cyanosis.  They  are  beneficial 
mainly  by  their  expectorant  effect,  producing  increased  secre- 
tion of  mucus  and  the  expectoration  of  that  which  has  accu- 
mulated, and  sometimes  causing  the  throwing  off  of  membrane 
which  is  only  loosely  attached.  They  usually  give  temporary 
relief,  at  least. 

While  the  syrup  of  ipecacuanha,  or  of  ipecacuanha  and 
squills,  in  doses  of  half  a  teaspoonful  to  a  teaspoonful,  or  sul- 
phate of  copper  in  doses  of  two  to  five  grains,  repeated,  if 
necessary,  in  fifteen  minutes,  will  render  excellent  service  in 
many  cases,  the  yellow  sulphate  of  mercury  is  usually  to  be 
preferred  as  being  most  reliable,  prompt  and  thorough  in  its 
action.  The  dose  is  from  three  to  five  grains.  To  much  pre- 
viously published  testimony  to  the  especial  utility  of  this 
emetic  I  am  permitted  to  add  the  following  statement  by  Dr. 
O'Dwyer:   "In  what  may  be  called  sthenic  cases,  when  the 


TREATMENT.  243 

dyspnoea  becomes  urgent  and  abiding1,  or,  in  other  words,  when 
it  is  time  to  operate,  prompt  vigorous  emesis,  such  as  is  pro- 
duced by  the  yellow  sulphate  of  mercury,  often  gives  marked 
relief,  which  sometimes  lasts  long  enough  to  render  a  repeti- 
tion of  the  vomiting  safe,  if  stimulants  and  nourishment  be  ad- 
ministered in  the  interim.  By  this  means  I  have  succeeded  in 
getting  a  good  many  cases  through,  especially  those  that  had 
been  placed  on  the  bichloride  treatment  at  the  commencement 
of  the  disease,  that  would  otherwise  have  required  intubation." 

In  asphyxia  emetics  usually  fail  to  acfc.  In  this  condition 
it  is  said  that  the  emetic  action  of  apomorphia  is  not  interfered 
with.  It  should  be  freshly  prepared.  Its  hypodermic  admin- 
istration in  doses  not  to  exceed  one  centigramme  is  recom- 
mended b}r  Mufioz.1  In  this  condition,  however,  it  need  hardly 
be  said  that  not  an  emetic,  but  intubation  or  tracheotomy,  is 
the  remedy  which  should  be  employed. 

In  those  cases  in  which  a  frequent,  harsh  and  painful  cough 
is  accompanied  with  recurrent  paroxysmal  dyspnoea,  an  opiate 
is  useful — as,  for.  instance,  Dover's  powder  or  its  liquid  equiva- 
lent, the  tinct.  ipecacuanhas  et  opii  of  the  Pharmacopoeia,  in 
doses  proportionate  to  the  age  and  the  amount  of  pain  and 
irritation.  The  good  effect  of  the  remedy  may  be  aided  by  the 
application  of  warm  flax-seed  poultices,  to  which  a  small  pro- 
portion of  mustard  has  been  added. 

The  remarks  made  as  to  the  importance  and  the  methods 
of  maintaining  nutrition  in  other  forms  of  diphtheria  are 
equally  applicable  in  reference  to  this  one.  In  proportion  as 
the  strength  is  taxed  by  the  persistent  dyspnoea,  and  in  pro- 
portion as  the  amount  of  nutritious  food  which  the  patient 
will  take  is  diminished,  the  giving  of  alcoholic  stimulants  be- 
comes the  more  necessary,  and  is  consequently  required  in 
most  cases  of  any  severity  or  duration.  After  tracheotomy 
or  intubation,  this  necessity  usually  becomes,  from  the  latter 
of  the  reasons  referred  to,  even  more  imperative. 
!E1  Prog.  Grinecol.,  July  10,  1887. 


214.  diphtheria;  its  nature  and  treatment. 

Laryngeal  diphtheria  may  doubtless  be  prevented  or  cured 
by  the  early  employment  of  the  measures  which  have  now 
been  referred  to,  in  a  considerable  proportion  of  cases;  but 
since  its  initial  symptoms,  such  as  huskiness  of  the  voice  and 
croupy  cough,  even  when  they  occur  in  connection  with  other 
forms  of  the  disea  se,  can  by  no  means  be  regarded  as  pathog- 
nomonic signs  pf  a  pseudo-membranous  affection  of  the  larynx, 
these  results  cannot  be  statistically  estimated.  It  must  be 
admitted  that  in  a  large  proportion  of  all  cases  of  unquestion- 
able laryngeal  diphtheria,  medical  treatment  alone  is  inade- 
quate to  prevent  a  fatal  termination.  This  proportion  has 
been  estimated  by  Morell  Mackenzie1  at  ninety  per  cent. 
Sanne 2  states  that  in  2809  cases  of  croup  which  have  been  en- 
tered at  the  Hopital  Sainte  Eugenie,  240,  that  is  1  in  13,  have 
recovered  without  operation. 


Tracheotomy. 

When  the  respiration  is  so  seriously  interfered  with  in 
laryngeal  diphtheria  that  asphyxia  is  imminent,  operative  in- 
terference is  usually  the  only  resource  by  which  the  life  of  the 
patient  can  be  saved.  There  can  be  no  doubt  that  intubation 
will  in  the  future,  to  a  greater  or  less  extent,  take  the  place  of 
tracheotomy  in  fulfilling  this  indication ;  but  since  that  opera- 
tion, as  it  is  now  practiced,  with  its  general  and  special  indica- 
tions, will  be  subsequently  treated  of  by  its  inventor,  Dr. 
Joseph  O'Dwyer,  I  shall  confine  my  remarks  to  tracheotomy. 

The  utility  of  tracheotomy  as  a  means  of  saving  life  is,  in  a 
general  sense,  sufficiently  illustrated  by  comparing  with  the 
estimate  just  quoted  of  the  ratio  of  recoveries  in  cases  of 
membranous  croup  not  operated  upon,  the  following  statistics 
of  the  recoveries  in  "  all  available  reported  cases "  in  which 
tracheotomy  had  been  performed  previous  to  1887,  as  compiled 

1  Op.  eit.,  p.  89.  2Op.  cit.,  p.  490. 


TREATMENT. 


245 


in  an  interesting-  and  instructive  paper  by  Drs.  Lovett  and 
Munro : * 


Total. 

Recovered. 

Died. 

Per  Cent 
Recovered. 

German  authors      .... 
German  hospitals    .... 

British  authors 

French  authors 

Various  countries     .... 
American  authors   .... 

5795 
3063 
433 
9242 
1993 
1327 

1851 
939 
138 

2242 
657 
308 

3944 
2124 
295 
6834 
.1336 
1019 

31 
30 
31 
24 
32 
23 

21,853 

6135 

15,552 

28 

Tracheotomy  has,  in  many  considerable  series  of  cases, 
been  attended  with  a  much  larger  proportion  of  recoveries,  as 
is  illustrated  in  the  folio  wing"  examples : 


Per  cent,  of 
Operations  Recoveries   Recoveries 


60 


48T", 


To 


34 

63 

82 

f  2-2- 

13 

72-3- 

'"'10 

Surgical  Clinic  in  Konigsberg, 

1878-1882,  (Plenio 2)  .  ..  .  123 
Tracheotomies  by  H.  Ranke,3  Munich, 

April  1,  1878,  to  Sept.  1,  1885.  .  54 
Tracheotomies  by  A.  Caselli 4  .  .  132 
Ibid  (with  improved  instruments)    .       18 


The  results  of  tracheotomy  differ  widely  according  to  a 
great  variety  of  circumstances,  of  which  the  following  are 
especially  important : 

1.  The  methods  and  skill  employed  in  the  operation  and 
the  after-treatment. 

2.  The  age  of  the  patient. — The  results  of  tracheotomy  are 
very  unfavorable  in  infants,  and  in  older  children  improve  in 


1  "A  Consideration  of  the  Results  in  327  Cases  of  Tracheotomy  Per- 
formed at  the  Boston  City  Hospital  from  1864  to  1887 ;  by  Robert  W. 
Lovett,  M.D.,  and  John  C.  Munro,  M.D.,"  American  Journal  of  the 
Medical  Sciences,  1887,  vol.  xciv.,  p.  160. 

2  Jahrb.  f.  Kinderh.,  Bd.  xxii.,  H.  4. 
3Jahrb.  f.  Kinderh.,  Bd.  xxiv.,  p.  225. 
4Gaz.  Med.  Ital.  Loinb.,  1887,  p.  198. 


246 


diphtheria;  its  nature  and  treatment. 


proportion  to  the  age.  Dr.  Gustav.  Chagin1  has  collected  the 
.statistics  of  977  operations  in  infants,  of  whom  only  15  per 
cent,  recovered. 

M.  Sanne 2  thus  states  the  results  of  tracheotomies  at  the 
Hopital  Sainte  Eugenie  according  to  the  age  of  the  patients: 

Age.  Cases.     Recoveries.     Percent. 


1  to    2  years 

653 

88 

13.6 

3  "     5    "      . 

.     1298 

285 

21.9 

6  "  10     "       . 

.       335 

127 

37.8 

1  "  15    "      . 

26 

9 

32.3 

Dr.  H.  Settegast 3  has  tabulated  the  results  of  tracheoto- 
mies in  the  Krankenhause  Bethanien  (1861  to  1877)  as  follows: 


2  to 

3  " 

4  " 

5  " 

6  " 


Age. 

3  years, 

4  " 

5  " 

6  " 


9 


9 
10 


Cases. 

Recoveries. 

Per  cent 

93 

22 

23.65 

165 

47 

28.45 

175 

54 

30.85 

107 

39 

35.45 

90 

34 

OI.il 

59 

17 

38.86 

24 

11 

45.83 

.       15 

6 

40 

3.  The  type,  as  to  fatality,  of  the  prevailing  disease. — This 
has  been  remarked  by  most  writers  on  the  subject.  Lovett 
and  Munro4  state  that  the  tracheotomy  death-rate  at  the 
Boston  City  Hospital  from  1881  to  1885  inclusive,  varied  by 
the  month  in  the  closest  correspondence  to  the  mortality  per 
cent,  of  diphtheria  for  the  same  time  in  the  whole  city  of 
Boston. 

4.  The  season  of  the  year. — The  writers  just  quoted  from 
state  that  during  the  same  five  3-ears  (1881-1885)  not  twenty 
per  cent,  recovered  of  those  operated  upon  in  December,  Jan- 
uary, February  and  March,  "while  from  the  latter  month  the 

'Archiv.  f.  Kinderh.,  Bd.  iv.  2Op.  cit.,  p.  485. 

3  Langen beck's  Archives,  Bd.  xxii.,  p.  882.  4Loc.  cit. 


TREATMENT.  247 

recovery  rate  rises  until  July,  when  about  sixty  per  cent,  of 
all  cases  operated  upon  get  well." 

M.  Sanne  states  that  the  results  of  all  the  tracheotomies 
at  the  Sainte  Eugenie  up  to  1876  give  the  following  ratios  of 
recoveries:  for  June,  1  to  3.31;  for  August,  1  to  3.56;  for  No- 
vember, 1  to  7.19;  for  December,  1  to  6.18;  and  for  January, 
1  to  5.04. 

5.  The  stage  of  the  disease. — It  is  a  well-established  fact 
that  the  prospect  of  the  successful  result  of  tracheotomy  is 
the  greater  the  earlier  it  is  performed  after  the  nature  of  the 
disease  requiring  it  is  recognized.  This  is  further  illustrated 
by  the  following  figures  in  the  article  of  Lovett  and  Munro 
from  which  I  have  previously  quoted: 

The  time  is  reckoned  from  the  beginning  of  obstructed 
respiration. 

Day  of  Operation. 

1  . 

2  . 

3  . 

4  . 

6.  The  condition  of  the  patient. — The  most  favorable  re- 
sults from  tracheotomy  may  be  expected  when  the  previous 
health  of  the  patient  has  been  good  and  the  disease  is  primary 
and  uncomplicated.  The  prospect  of  success  is  generally  bad 
in  secondary  diphtheria,  and  when  the  laryngeal  affection  ac- 
companies a  malignant  or  septic  form  of  diphtheria,  or  is  at- 
tended with  pseudo-membranous  bronchitis,  broncho-pneumo- 
nia or  other  grave  complications. 

These  unfavorable  conditions  are  regarded  by  some  as 
contra-indications  to  the  operation.  This  may  doubtless  in- 
sure the  avoidance  of  many  bad  results.  Dr.  J.  Lewis  Smith 
states  that  a  surgeon  of  this  city  (Dr.  A.  E.  Robinson)  who 
carefully  selects  his  cases,  operates  early  and  deliberately, 
and  supervises  by  frequent  visits  the  after-management,  has 
saved  since  1880  eleven  in  thirteen  consecutive  cases  of  un- 


ises. 

Recoveries. 

Per  cent 

23 

40 

32.5 

86 

24 

28.0 

33 

8 

25.3 

7 

1 

14.0 

Extension. 

Septicaemia. 

1  2 

to 

1 

34 

to 

1 

H 

to 

1 

248  DIPHTHERIA;    ITS    NATURE    AiTD    TREATMENT. 

doubted  membranous  croup.  Yet  since  the  primary  object  of 
tracheotomy  is  simply  to  relieve  asphyxia,  and  since  there 
have  been  instances  of  subsequent  recovery  under  the  most 
unfavorable  conditions,  it  would  seem  to  be  property  indicated 
in  all  cases  in  which  it  is  probable  that  death  by  suffocation 
would  take  place  without  it. 

Another  indication  for  the  operation  is  often  urged,  namely, 
that  even  if  it  fails  to  save  life  it  will  secure  euthanasia.  The 
statements  of  Lovett  and  Munro  on  this  point  are  important. 
In  232  fatal  cases  the  proportion  of  deaths  from  the  extension 
of  the  disease  downward  into  the  trachea  and  bronchi  to  those 
from  septicaemia  were  as  follows  : 

In  all  the  fatal  cases 

In  children  under  2  years 

In  children  from  2  to  10  years 

The  writers  remark,  "  It  will  be  seen  from  this  that  young 
children  are  particularly  liable  to  that  distressing  cause  of 
death,  extension  of  the  process  to  the  bronchi.  When  this 
happens  there  is  no  euthanasia;  death  is  the  slowest  and  most 
painful  of  suffocations,  and  only  when  septicaemia  to  the  point 
of  stupefaction  is  present  at  the  same  time  does  the  child  es- 
cape a  horrible  amount  of  suffering." 

In  favor  of  early  tracheotomj"  the  unquestionable  fact  is 
urged  that,  in  the  words  of  Trousseau,  "  the  earlier  the  opera- 
tion is  performed  the  greater  are  the  chances  of  success,"  and 
that  the  danger  of  the  unexpectedly  rapid  occurrence  of  fatal 
asphyxia  is  thereby  avoided.  On  the  other  hand  it  is  argued 
that  in  a  certain  proportion  of  cases  recovery  does  take  place 
without  operation,  and  that  when  the  patient  can  be  vigilantly 
watched  and  the  operator  can  be  promptly  summoned  in  case 
of  need,  medical  treatment  should  first  be  tried,  and  the  opera- 
tion performed  only  when  asphyxia  is  imminent.  This  ques- 
tion must  be  decided  in  each  particular  case  by  a  due  consid- 


TREATMENT.  249 

eration  of  the  circumstances  attending-  it.  That  an  ersor  in 
the  direction  of  unnecessary  earliness  is  a  safer  one  than  that 
of  too  great  procrastination,  has  been  illustrated  in  many  mel- 
ancholy instances.  Now  that  the  alternative  of  intubation  is 
available,  man}^  of  the  perplexities  which  formerly  beset  the 
ohysician  in  making  this  decision  are  happily  removed. 

Another  indication  for  the  early  performance  of  tracheo- 
tomy has  lately  been  suggested  which  will,  in  my  opinion, 
assume  greater  prominence  the  more  our  knowledge  of  the 
pathology  and  treatment  of  the  disease  is  perfected.  Mr.  W. 
W.  Chejme,1  in  view  of  the  pathological  fact  that  "  in  almost 
all  cases  the  membrane  appears  first  in  the  larynx  and  spreads 
thence  continuously  down  the  trachea/'  proposes  that  trache- 
otomy be  performed  with  the  greatest  possible  antiseptic  pre- 
cautions as  soon  as  it  is  evident  that  there  is  a  membranous 
affection  of  the  larynx,  with  the  object  of  preventing,  by  suita- 
ble disinfectant  treatment  applied  through  the  tracheal  open- 
ing to  the  mucous  membrane  of  the  larynx  and  trachea,  the 
downward  spread  of  the  diphtheritic  process.  In  order  to 
accomplish  this  it  is  necessary  that  the  trachea  be  opened 
more  freely  than  is  usual,  so  that  through  the  opening  the 
interior  of  the  trachea  may  be  inspected  and  antiseptic  appli- 
cations may  be  made  upward  into  the  larynx  and  over  the 
mucous  membrane  of  the  trachea.  The  details  of  one  case  are 
given,  in  which  by  removing  the  advancing  membrane  in  the 
trachea  by  dissecting  forceps  and  sponging  the  surface  with  a 
1  in  500  solution  of  bichloride  of  mercury,  its  progress  was 
arrested. 

A  different  application  of  the  same  principle  is  reported  by 
Roser.2  At  the  Marburg  surgical  clinic  the  cannula  used  in 
tracheotomy  has  been  surrounded  with  an  antiseptic  tampon 
prepared  in  the  following  manner :  The  cannula  is  wound  with 
a  muslin  bandage  which  has  first  been  moistened  with  a  solu- 

1  British  Medical  Journal,  March  5,  1887,  p.  505. 

2  Revue  Mens,  des  Mai.  de  TEnf.,  June,  1888. 


250  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

tion  of  sublimate.  While  it  is  still  moist  it  is  sprinkled  with 
powdered  iodoform.  This,  when  dry,  forms  a  crust  which  ad- 
heres to  the  cannula.  When  the  instrument  thus  prepared  is 
inserted  into  the  trachea,  the  muslin  swells  again  and  forms  a 
tampon.  Its  calibre  must  be  such  as  to  exactly  fill  the  trachea. 
Thus  is  constituted  an  antiseptic  barrier  which  the  advancing 
diphtheritic  process  cannot  pass.  It  is  left  in  the  trachea  two 
days,  and  is  then  replaced  by  a  fresh  one,  which  is  left  until  the 
fifth  day.  Of  forty-seven  tracheotomized  diphtheritic  patients 
thus  treated  during-  the  past  three  years  there  have  been  fifty- 
three  per  cent,  of  recoveries. 

The  Operation. 

The  high  operation,  in  which  the  opening  is  made  into  the 
upper  portion  of  the  trachea,  is  now  generally  preferred  as  the 
easier,  safer  and  more  expeditious  one. 

The  patient,  wrapped  in  a  blanket,  should  be  laid  on  his 
back  on  a  table  so  placed  that  his  left  side  shall  be  toward  the 
window  or  artificial  light,  and  his  neck  should  be  extended  by 
having  placed  under  it  an  ordinary  wine-bottle  wrapped  in  a 
napkin. 

Then  chloroform  should  be  given,  unless  the  patient  is 
already  asphyxiated  or  narcotized  by  septic-poisoning.   - 

The  operator  should  stand  to  the  right  of  the  patient. 

An  incision  through  the  skin  should  be  made  downward 
from  the  cricoid  cartilage  exactly  in  the  median  line  for  one 
and  one-half  inches,  or  more,  if  necessary. 

The  tissues  should  then,  under  ordinary  circumstances,  be 
carefully  and  deliberately  dissected  down  to  the  trachea,  the 
edges  of  the  wound  being  separated  by  retractors,  and  vessels 
being  avoided  and  put  aside. 

If  the  isthmus  of  the  thyroid  body  is  unusually  high,  it  may 
be  displaced  downward,  the  muscular  and  ligamentous  bands 
by  which  it  is  attached  to  the  hyoid  bone  and  thyroid  carti- 
lage above  having  first  been  divided  with  curved  scissors  on 


TREATMENT.  251 

either  side  of  the  incision  opposite  the  first  ring-  of  the  trachea.1 
"  But  in  the  immense  majority  of  cases,"  says  Sanne,  "this  por- 
tion of  the  gland  is  only  a  thin  strip  which  passes  unnoticed." 


Fig.  21.— Pilcher's  Retractor. 


All  bleeding  should  be  arrested  by  the  forceps,  clamps  or 
ligature  before  the  trachea  is  opened.  Then  the  point  of  the 
knife  should  be  carried  into  the  trachea,  and  the  two  or  three 
upper  rings  divided. 


Fig.  23.— Double  Trachea  Tube.    Blovable  Plate.    Silver. 

The  opening  of  the  trachea  is  announced  by  the  escape  of 
air.  Fragments  of  false  membrane  sometimes  present  them- 
selves at  the  opening  and  are  coughed  out,  or  may  be  extracted 
by  forceps.     It  is  often  advisable,  before  introducing  the  can- 


Fig.  23.— Trousseau's  Dilator. 


nula,  to  excite  coughing  by  inserting  a  feather  downward  into 
the  trachea,  that  blood,  mucus  or  fragments  of  false  mem- 
brane may  be  expelled. 

^r.  J.  A.  Wyeth:  "A  Text  Book  on  Surgery.1'  p.  453. 


252  DIPHTHERIA;    ITS   NATURE   AND   TREATMENT. 

The  cannula  may  be  introduced  by  using  the  nail  of  the 
left  index-finger  as  a  guide  into  the  tracheal  incision,  or  by 
the  aid  of  the  dilator.  Difficulties  in  doing  this  should  be 
overcome  by  repeated  gentle  efforts,  but  never  by  force. 

A  rapid  operation  is  practiced  and  described  by  Sanne,1 
and  advocated  by  Renault.2  The  trachea  is  grasped  by  its 
sides  at  the  level  of  the  thyroid  cartilage,  between  the  thumb 
and  middle  fingers  of  the  left  hand,  while  the  index-finger  of 
that  hand  finds  the  cricoid  cartilage,  the  finger-nail  being 
placed  upon  its  lower  border.  This  hand  must  not  be  removed 
until  the  cannula  has  been  inserted. 

The  incision  having  been  made  through  the  skin  downward 
from  the  point  indicated  by  the  finger-nail,  a  few  additional 
strokes  of  the  knife  bring  one  to  the  trachea.  The  bleeding  is 
not  usually  of  any  importance  in  this  situation.  The  trachea, 
being  felt  by  the  left  index-finger,  is  punctured  and  incised. 
Then  the  cannula  is  taken  in  the  right  hand,  and,  guided  by 
the  left  index-finger,  which  remains  in  the  wound,  is  inserted 
into  the  tracheal  opening. 

In  this  operation  the  prompt  insertion  of  the  cannula  is 
relied 'upon  to  arrest  the  haemorrhage;  but  this  promptness 
requires  that  the  operator  be  expert  in  tracheotomy.  Except 
when  the  rapid  completion  of  the  operation  is  especially  called 
for,  the  more  deliberate  method  should  be  preferred. 

To  prevent  infection  of  the  wound  it  should  be  sponged 
with  an  antiseptic  solution  before  the  trachea  is  incised,  and 
at  the  completion  of  the  operation  should  be  dusted  with  iodo- 
form and  dressed  with  two  thicknesses  of  linen,  which  should 
be  moistened  every  hour  with  a  solution  of  the  bichloride  of 
mercury  (one  in  two  thousand). 

In  the  after-treatment  it  is  very  important  that  the  air  of 
the  room  be  kept  at  a  proper  and  uniform  degree  of  warmth 
and  moisture.     The  diffusion  through  it  of  unirritating  anti- 

>Op.  cit.,p.  522. 

2 "Manuel  de  Tracheotoniie,"  by  Dr.  P.  Renault;  Gr.  Steinheil,  6diteur. 


TREATMENT.  258 

septic  vapors,  such  as  have  already  been  referred  to  (page  197), 
is  a  valuable  addition. 

The  tube  must  be  vigilantly  and  intelligently  watched. 
Whenever  it  becomes  obstructed  by  the  discharges  or  frag- 
ments of  false  membrane,  the  inner  tube  must  be  withdrawn 
and  cleansed. 

The  use  of  mild  antiseptic  atomized  solutions  administered 
with  the  inspired  air  through  the  tube  may  be  practiced. 
The  spray  of  carbolic  acid  and  lime-water  (page  215)  is  es- 
pecially appropriate.  Mild  solutions  of  borax  or  boracic  acid 
may  be  similarly  used,  or  insufflations  of  iodoform,  as  referred 
to  on  page  186. 

If  there  is  false  membrane  below  the  tube,  the  frequent  in- 


Fig.  24.— Trousseau's  Tracheal  Forceps. 


troduction  of  solutions  of  trypsin  or  papayotin  in  spray,  or  by 
means  of  a  slender  quill,  may  be  resorted  to. 

The  dislodgment  and  removal  of  obstructing  membrane 
below  the  tube  has  in  some  cases  been  effected  by  means  of 
forceps  or  the  croup-brush,  or  an  instrument  which  is  made  by 
surrounding  the  end  of  a  soft  flexible  urethral  catheter  with  a 
ring  five  or  six  millimetres  in  diameter.1 

After  the  expiration  of  twent3T-four  hours  from  the  opera- 
tion, and  at  such  subsequent  intervals  as  are  requisite,  the 
cannula  should  be  removed  to  facilitate  the  ejection  of  ac- 
cumulated matter  from  the  trachea  and  the  inspection  and 
dressing  of  the  wound. 

When  air  begins  to  pass  through  the  larynx,  the  cannula 
may  be  removed  for  a  short  time,  which  may  be  repeated  and 
the  time  extended  as  the  patient  becomes  more  able  to  dis- 

1  Roser,  Loc.  cit. 


254  diphtheria;  its  nature  and  treatment. 

pense  with  it,  until  it  is  finally  removed  altogether.  The  length 
of  time  from  the  first  insertion  to  the  final  removal  of  the 
cannula  varies  very  greatly  in  different  cases.  In  a  large 
majority  of  all  cases  this  period  does  not  exceed  eight  days, 
hut  in  some  instances  it  is  several  months  or  even  years. 

The  Treatment  of  Diphtheritic  Paralysis. 

Since  diphtheritic  paralysis  is  due  to  the  immediate  or 
remote  effect  upon  the  nervous  system  of  the  diphtheritic 
poison,  and  since  it  usually  disappears  pari  passu  with  the 
accompanying  anaemia,  the  measures  especially  indicated  in 
its  treatment  are  those  which  tend  to  counteract  the  former 
and  remove  the  latter.  These  are  rest,  fresh  air  and  a  restora- 
tive regimen.  Among  drugs  the  tincture  of  the  chloride  of 
iron,  the  actions  of  which  as  a  haemic  restorativej  a  stimulant 
tonic,  and  an  eminently  efficient  antidote  to  the  debilitating 
poison  of  diphtheria  have  been  elsewhere  referred  to,  is  in- 
comparably the  most  useful.  My  own  experience  in  the  treat- 
ment of  quite  a  large  number  of  cases  has  furnished  a  striking 
illustration  of  this  fact.  The  medicinal  treatment  of  these 
cases  has  invariably  consisted  mainly  in  the  continued  fre- 
quent administration  of  iron  by  one  of  the  formulae  given  on 
page  220.  The  rapidity  with  which  the  paralysis  has  disap- 
peared, even  in  some  grave  cases,  has  been  remarkable. 

The  tendency  of  the  affection,  in  the  great  majority  of  cases, 
to  early  recovery,  and,  even  in  the  more  severe  and  persistent 
ones,  to  an  ultimate  restoration  of  function,  which  is  often 
rapid  when  it  has  once  commenced,  would  naturally  lead  to 
the  attributing  of  special  curative  virtues  to  whatever  drug 
or  method  of  treatment  might  chance  to  have  been  employed. 
Hence  strychnine  and  electricity  have  received  a  large  meed 
of  credit  for  many  recoveries. 

With  regard  to  the  beneficial  effect  of  electricity  experience 
and  opinions  differ.  Dr.  A.  D.  Rockwell,  of  this  city,  informs 
me  that  according  to  his  experience  in  a  considerable  number 


TREATMENT.  255 

of  cases  it  has  seemed  to  shorten  the  duration  of  the  affection. 
Seeligmiiller '  attaches  much  importance  to  its  use.  The  con- 
stant current  should  be  employed.  When  the  velum  palati  is 
affected  the  positive  pole  should  be  placed  on  the  nucha,  the 
negative  one  under  the  inferior  maxilla;  in  ocular  paralysis, 
the  positive  pole  on  the  nucha,  and  the  negative  in  the  vicinity 
of  the  paralyzed  muscles;  in  paralysis  of  the  lower  extremities, 
the  positive  over  the  lumbar  region  and  the  negative  over  the 
nerves  which  are  to  be  excited.  Gowers a  recommends  the  use, 
in  severe  cases,  of  the  voltaic  current,  slowly  interrupted,  in 
such  strength,  if  possible,  as  will  cause  the  affected  muscles  to 
contract;  but  in  the  case  of  children  the  use  of  a  weaker  cur- 
rent is  far  preferable  to  the  exciting  of  distress  and  alarm  by 
a  stronger  one,  "since  the  utmost  good  that  electricity  can  do 
is  very  small  compared  with  the  harmful  influence  of  a  daily 
fright."  Gentle  friction  or  massage  over  the  affected  region 
often  seems  to  be  beneficial,  but  any  violent  or  fatiguing  pro- 
cedures of  the  kind  are  strongly  contra-indicated. 

Strychnine  in  small  doses  may  doubtless  render  valuable 
service  in  aiding  to  restore  the  tone  and  activity  of  the  diges- 
tive organs.  Gowers 3  says  that  while  it  sometimes  seems  to 
be  of  service  "  it  is  certainly  powerless  to  neutralize  the  mor- 
bid process  in  its  early  stages,  and  seems  to  be  without  influ- 
ence on  the  spread  of  the  disease.  Moreover  it  is  not  wise  to 
give  large  doses  of  a  drug  that  stimulates  the  nerve-cells  so 
powerfully."  In  cases  of  extreme  paralysis  of  the  muscles  of 
deglutition  and  respiration,  its  hypodermic  use  has  seemed  to 
be  beneficial.  Reinard,4  reports  a  favorable  result  of  the  daily 
injection  of  one  milligramme  (^  grain)  of  sulphate  of  strych- 
nia in  a  desperate  case  of  general  diphtheritic  paralysis  in- 
volving the  muscles  of  respiration.  After  the  first  injection 
respiration  was  easier,  and  a  cure  was  effected  in  fifteen  days. 

1  E.  Adler :  Med.  Chirurg.  Rundschau,  No.  4,  1886. 

2  Diseases  of  the  Nervous  System,  p.  1236. 
3Loc.  cit. 

"Deutsche  Med.  Wochenschrift,  1885,  No.  9. 


256  diphtheria;   its  natube  and  treatment. 

Dr.  W.  H.  Thomson1  has  found  the  recourse  to  strych- 
nia and  electricity  very  disappointing-;  but  he  states  that 
topical  irritants  seem  occasionally  to  be  quite  effective.  In 
palatine  and  pharyngeal  paralysis  he  brushes  the  parts 
every  few  tours  with  a  paste  of  black  pepper  and  honey,  with 
a  view  to  awakening  their  lost  reflex  excitability.  In  paraly- 
sis of  the  limbs,  trunk,  etc.,  he  has  the  parts  enveloped  twice 
a  day  in  a  pack  of  infusion  of  capsicum  of  the  strength  of  a 
drachm  of  the  powder  to  a  pint  of  boiling  water,  the  applica- 
tion to  last  from  ten  to  twenty  minutes. 

The  difficulty  of  deglutition  is,  in  some  cases,  one  of  the  most 
serious  complications  to  overcome.  When  the  paralysis  is  in 
the  palate,  solid  or  semi-solid  food  can  be  swallowed ;  but  when 
the  muscles  of  the  pharynx  and  upper  part  of  the  larynx  are 
affected,  with  insensibility  of  the  epiglottis,  the  administering 
of  food  by  the  ordinary  means  becomes  dangerous  or  impossi- 
ble from  its  tendency  to  enter  the  larynx.  In  such  cases  resort 
must  be  had  to  the  oesophageal  tube  or  a  large  catheter  or  to 
rectal  enemas.  The  necessity  of  giving  nourishment  by  one 
or  both  of  these  methods  is  imperative  in  order  to  avoid  the 
danger  of  exhaustion. 

In  the  case  of  serious  dyspnoea  and  danger  of  suffocation 
from  the  accumulation  of  mucus  in  the  bronchial  tubes  in 
paralysis  of  the  respiratory  muscles,  resort  to  artificial  respira- 
tion may  tide  the  patient  over  a  dangerous  emergency.  Dr. 
W.  H.  Thomson  suggests  that  in  such  cases  the  treatment 
which  is  so  successful  in  cases  of  bronchial  palsy  be  tried. 
"  The  patient  should  be  let  down  on  his  hands  from  the  bed 
with  his  head  down,  and  encouraged  to  cough,  and  frequently 
a  short  recourse  to  this  measure  will  result  in  expelling  a 
quantity  of  suffocative  fluids  from  the  trachea  with  great  relief 
to  the  respiration  for  some  time."  In  such  cases  the  applica- 
tion of  the-  f aradic  current  to  the  skin  of  the  back  of  the  chest 

1  Medical  News,  June  4,  188,8,  p.  635. 


TREATMENT.  257 

with  a  view  to  the  reflex  stimulation  of  the  respiratory  centre 
has  been  found  promptly  serviceable  by  Duchenne.1 

For  the  sudden  heart-failure  which  sometimes  occurs  in  the 
first  or  second  week  of  diphtheria,  all  remedies  are  too  often 
unavailing-.  The  patient  must  be  kept  strictly  quiet  in  the 
recumbent  position.  A  hot  poultice,  over  which  mustard  has 
been  dusted,  should  be  applied  over  the  cardiac  region.  Warm 
stimulating  applications  and  rubbing  should  be  kept  up  over 
the  extremities.  Brandy  or  whiskey  should  at  once  be  given 
hypodermically,  and  small  doses  of  digitalis  may  be  given  in 
the  same  manner.  Faradization  over  the  cardiac  region  is 
recommended  by  Duchenne  as  a  powerful  cardiac  stimulant 
under  such  circumstances.  Ammonia,  camphor,  musk,  and 
other  stimulants  are  recommended,  but  are  of  doubtful  utility, 
especially  as  the  tolerance  of  the  stomach  for  drugs  and  food 
is  usually  very  limited,  and  should  be  carefully  economized.  I 
have  seen  small  doses  of  coffee  and  of  beef-juice,  and  cham- 
pagne given  pretty  freely,  well  retained  and  beneficial.  By 
the  judicious  use  of  the  measures  referred  to,  the  patient  may 
sometimes  be  carried  through  an  alarming  emergency,  though 
too  often  their  good  effect  is  only  transient. 

The  milder  forms  of  cardiac  paralysis,  which  usually  appear 
at  a  later  period  in  connection  with  other  forms  of  diphtheritic 
palsy,  may  be  treated  by  the  remedies  which  have  been  already 
referred  to  as  appropriate  for  that  condition,  with  the  addition 
of  small  doses  of  digitalis;  and  the  special  danger  of  any  vio- 
lent exertion  or  even  of  suddenly  rising  from  the  recumbent 
position  should  always  be  borne  in  mind. 

Diphtheritic  Conjunctivitis. 

In  the  treatment  of  diphtheritic  conjunctivitis,  the  follow- 
ing measures  are  indicated  : 

In  the  first  stage,  small  pieces  of  lint,  cooled  on  a  block  of 
ice,  should  be  laid  over  the  eye  and  changed  ever}^  minute  or 

J"  Selections  from  the  Works  of  Duchenne,"  by  Dr.  Poore,  p.  350. 

17 


258  diphtheria;  its  nature  and  treatment. 

two;  in  the  second  stage  warm  or  moderately  cold  applica- 
tions should  be  used  according-  to  the  sensations  of  the  patient. 

Antiseptic  solutions,  such  as  mercuric  bichloride  (1  in  8000), 
carbolic  acid  (30  minims  to  the  pint),  or  boric  acid  (one  to  four 
drachms  to  the  pint)  should  be  dropped  into  the  eye  hourly. 
The  most  thorough  cleanliness  must  also  be  maintained  by 
irrigation  with  the  same  or  weaker  solutions,  used  warm  or 
tepid.     Dusting  iodoform  into  the  eye  has  been  recommended. 

In  the  third  stage  astringent  solutions,  as  of  nitrate  of 
silver  (5 — 10  grains  to  the  ounce),  or  tannin  (20  grains  to  the 
ounce)  applied  once  or  twice  a  day  are  useful. 

In  case  of  great  pressure  upon  the  cornea  from  the  swell- 
ing of  the  eyelid,  canthoplasty  should  be  performed. 

The  greatest  care  must  be  taken  to  prevent  the  infection 
of  the  sound  eye,  by  protecting  it  with  an  impermeable  cover- 
ing. 

Cutaneous  Diphtheria. 

The  ordinary  forms  of  cutaneous  diphtheria  usually  recover 
rapidly  when  simply  kept  clean,  dusted  over  with  iodoform, 
and  covered  with  lint,  which  is  kept  moistened  with  a  mild 
antiseptic  solution,  as  of  bichloride  or  carbolic  acid. 

The  more  serious  forms  of  wound-diphtheria,  which  some- 
times occur  in  hospitals,  should  be  treated  on  the  same  princi- 
ples as  hospital  gangrene.  The  false  membrane  and  necrosed 
tissues  should  first  be  destroyed  or  removed.  This  may  be 
done  by  means  of  the  gal vano-cautery ;  or  they  may  be  dis- 
sected away  as  completely  as  possible,  after  which  bromine  is 
applied,  and  then  the  wound  is  covered  with  iodoform,  and 
dressed  antiseptically. 


APPENDIX. 


A  recent  contribution  to  the  etiology  of  diphtheria *  by 
MM.  Roux  and  Yersin  of  the  Pasteur  Institute,  Paris,  has 
reached  me  too  late  for  its  statements  to  be  incorporated  into 
the  chapter  on  that  subject;  but  those  statements  are, prima 
facie,  so  important  in  view  of  the  corroboration  which  they 
furnish  to  previous  observations  which  have  been  referred  to 
in  that  chapter,  that  a  summary  of  them  is  here  appended. 

MM.  Roux  and  Yersin  have  found  the  bacillus  of  Klebs  and 
Loeffler  (described  on  page  37)  in  the  false  membranes  in  every 
one  of  fifteen  cases  of  human  diphtheria  examined  by  them. 
They  have  isolated  it  in  pure  cultures  by  methods  nearly  iden- 
tical with  those  of  Loeffler.  They  state  that  it  is  freely  repro- 
duced in  the  absence  of  air,  but  less  energetically  than  in  its 
presence.  It  maintains  its  vitality  for  a  long  time  in  nutritive 
media,  having  been  thus  preserved  for  more  than  six  months 
in  tubes  hermetically  sealed. 

The  cultures  made  by  the  authors  have  been  more  active 
than  were  those  of  Loeffler,  the  effect  of  their  inoculation  into 
animals  having  been  more  uniform  and  more  fatal,  but  in  most 
other  respects  the  results  of  their  experiments  have  been  iden- 
tical with  those  described  by  him. 

In  inoculations  of  the  culture  upon  mucous  membranes  they 
have  found  it  necessary  to  first  excoriate  them;  merely  smear- 
ing it  over  healthy  mucous  membranes  produces  no  result. 

1  "Contribution  a  l'Etude  de  la  Diphtherie,  par  E.  Roux  et  A.  Yer- 
sin," Annales  de  Tlnstitut  Pasteur,  Deeeuibre,  1888. 


260  diphtheria;  its  nature  and  treatment. 

The  affection  produced  by  inoculations  in  the  trachea  of  the 
rabbit  strikingly  recalls  the  features  of  human  croup — conges- 
tion of  the  mucous  membrane,  false  membrane,  cedematous 
swelling  of  the  tissues  and  the  glands  of  the  neck,  dyspnoea, 
stridulous  breathing,  asphyxia. 

Injections  of  the  culture  beneath  the  skin  of  pigeons,  rab- 
bits and  guinea-pigs,  in  sufficient  quantity,  caused  their  death 
in  from  thirty-six  hours  to  five  days,  the  period  varying  accord- 
ing to  the  susceptibility  of  the  animal  and  the  amount  of  the 
culture  introduced.  In  the  rabbit  the  autopsy  showed  at  the 
point  of  inoculation  an  extensive  oedema  infiltrating  a  tissue 
indurated  with  hemorrhagic  points,  swelling  of  glands,  con- 
gestion of  the  omentum  and  mesenter3r,  with  small  ecchymoses 
along  the  vessels ;  the  liver  friable,  of '  a  yellow  tint,  and  the 
seat  of  a  grayish  degeneration.  In  guinea-pigs,  which  are  the 
most  susceptible  to  the  action  of  the  bacillus  of  diphtheria,  the 
post-mortem  lesions  consisted  in  a  grayish  membranous  coat- 
ing at  the  point  of  inoculation,  a  gelatinous  oedema  of  greater 
or  less  extent,  a  general  dilatation  of  blood-vessels,  congestion 
of  glands  and  internal  organs,  especially  of  the  suprarenal 
capsules,  the  pleurae  being  often  filled  with  a  serous  effusion 
and  the  pulmonary  tissue  sometimes  in  a  state  of  splenization. 

After  intravenous  injections  in  rabbits  of  one  cubic  centi- 
metre of  the  culture,  the  animals  usually  died  within  sixty 
hours.  The  lesions  found  at  the  autopsy  were  a  general  con- 
gestion of  the  abdominal  organs,  dilatation  of  vessels,  swelling 
of  glands,  acute  nephritis,  and  the  hepatic  degeneration  already 
referred  to. 

Is  the  bacillus  from  a  very  infectious  case  of  human  diph- 
theria more  active  than  those  from  a  benign  case  ?  Without 
being  able  to  definitively  answer  that  question,  the  authors 
state  that  a  culture  from  the  false  membrane  of  a  very  benign 
case  was  found  to  be  very  active  when  inoculated  into  rabbits. 

From  the  results  of  a  large  number  of  careful  examinations 
the  authors  confirm  the  observations  of  Loeffier  and  others 


APPENDIX.  261 

that  the  bacillus  of  diphtheria  is  to  be  found  only  in  the  false 
membranes  and  at  the  point  of  inoculation,  and  never  in  the 
blood  or  the  organs,  except  transient^  and  accidentally  (as, 
for  instance,  within  a  few  hours  after  intravenous  injections) 
and  it  is  never  reproduced  there.  In  rabbits,  after  intravenous 
injection,  the  microbes  had  entirely  disappeared  within  sixteen 
hours ;  yet  the  malady  pursued  its  course,  and  the  rabbits  died 
in  from  thirty  to  thirty-six  hours. 

Diphtheritic  Paralysis. — MM.  Roux  and  Yersin  have  been 
the  first  to  succeed  in  experimentally  producing-  diphtheritic 
paralysis  in  animals.  They  have  produced  this  result  by  in- 
tratracheal, subcutaneous  or  intravenous  inoculations  in  nu- 
merous instances  in  which  the  animal  did  not  succumb  to  a  too 
rapid  intoxication.  Paralysis  commenced  in  a  pigeon  three 
weeks  after  inoculation  in  the  pharynx,  when  the  false  mem- 
branes had  disappeared  and  the  animal  seemed  to  have  com- 
pletely recovered.  The  powerlessness  of  the  feet  and  the  wings 
was  almost  complete.  When  this  muscular  feebleness  had 
continued  for  a  week  there  was  an  amelioration  in  the  move- 
ments of  the  feet,  but  the  rabbit  died  five  weeks  after  the  in- 
oculation. The  autopsy  showed  no  lesion,  either  of  the  articu- 
lations or  of  the  nervous  system,  to  account  for  the  symptoms. 
Man}^  of  the  localizations  which  occur  in  human  diphtheritic 
paralysis  were  observed  in  various  cases.  In  rabbits  the  first 
invasion  of  the  paralysis  was  usually  by  the  posterior  extrem- 
ities, and  it  progressed  so  rapidly  that  in  a  clay  or  two  it 
affected  the  whole  body,  and  the  animal  died  by  failure  of  the 
respiration  or  of  the  heart's  action.  In  rarer  instances  the 
paralysis  in  rabbits  began  in  the  muscles  of  the  neck,  the  rab- 
bit being  unable  to  raise  the  head  from  the  ground,  or  in  the 
larynx,  causing  hoarseness  of  the  voice.  The  authors  remark : 
"  The  occurrence  of  these  paralyses,  following  the  introduction 
of  the  microbe  of  Klebs  and  Loeffier,  completes  the  resemblance 
of  the  experimental  disease  to  the  natural  malady,  and  estab- 
lishes with  certainty  the  specific  role  of  that  bacillus." 


262  diphtheria;  its  nature  and  treatment. 

The  Diphtheritic  Poison. — The  truth  of  the  conclusion 
which  has  been  reached  by  Loeffler  and  others  that  the  bacillus 
exerts  its  morbific  effect  \>y  means  of  an  active  poison  which 
is  produced  by  the  microbe  at  the  seat  of  the  local  affection 
and  thence  diffused  through  the  system,  has  also  been  demon- 
strated by  the  experiments  of  MM.  Roux  and  Yersin.  They 
have  done  this,  not  by  isolating-  the  poison,  but  by  pursuing 
the  following  method:  Filtering  through  porcelain  a  pure 
culture  of  the  bacillus  in  bouillon  of  veal,  which  is  seven  days' 
old,  all  the  microbes  are  retained  by  the  filter,  and  the  liquid 
obtained  is  perfectly  limpid  and  slightly  acid.  If  this  liquid 
is  introduced  in  doses  of  from  two  to  four  cubic  centimetres 
beneath  the  skin  of  animals,  it  does  not  make  them  ill.  If, 
however,  a  dose  of  35  c.c.  is  injected  into  the  peritoneal  cavity 
of  a  guinea-pig  or  the  veins  of  a  rabbit,  the  animal  for  a  time 
appears  to  be  well,  but  after  two  or  three  days  becomes  inquiet 
and  trembles,  is  increasingly  feeble,  is  seized  with  a  profuse 
diarrhoea,  the  respiration  becomes  labored  and  irregular,  he 
is  no  longer  able  to  move,  and  dies  without  convulsions  five 
or  six  hours  after  the  commencement  of  the  symptoms.  A 
guinea-pig  which  has  received  35  c.c.  of  the  same  liquid  into 
the  peritoneum  dies  after  about  ten  hours,  having  experienced 
great  difficulty  in  respiration.  The  autopsy  shows  the  char- 
acteristic congestion  of  the  viscera,  especially  the  kidneys  and 
the  suprarenal  capsules,  and  there  is  often  a  pleuritic  effusion. 
If  quantities  of  the  filtered  liquid,  varying  from  \  c.c.  to  2  c.c, 
are  introduced  under  the  skin  of  guinea-pigs,  they  are  presently 
seized  with  the  same  symptoms,  and  die  in  the  same  manner, 
as  those  which  have  been  inoculated  with  the  living  culture, 
after  periods  varying  from  twenty-four  hours  to  three  days, 
according  to  the  dose  administered.  The  lesions  are  also  the 
same,  except  that  false  membrane  is  wanting.  There  is  the 
same  oedema,  the  same  indurated  tissue  at  the  point  of  inocu- 
lation, the  same  hemorrhagic  congestion  of  the  organs,  espe- 
cially of  the  kidneys  and  the  suprarenal  capsules,  and  the  same 


APPENDIX.  263 

pleuritic  effusion.  In  short,  "the  malady — both  symptoms 
and  lesions — is  communicated  as  certainly  by  the  injection  of 
the  filtered  poison  as  by  the  inoculation  of  the  bacillus." 

The  symptoms  produced  by  the  inoculations  of  the  filtered 
fluid,  vary  according"  to  the  dose  of  the  poison  contained  in  the 
culture.  In  the  case  of  a  guinea-pig-  dyspnoea  began  on  the 
fifth  day,  and  continued  for  a  week;  the  respiration  was  dia- 
phragmatic and  jerking.  When  the  animal  was  obliged  to 
run,  the  oppression  became  so  great  that  he  fell,  almost  as- 
phyxiated. These  symptoms  amended  gradually,  and  he  re- 
covered. In  rabbits  the  same  commencement  of  the  paralysis 
in  the  posterior  extremities  and  its  rapidly  fatal  generaliza- 
tion, which  has  been  already  described,  occurred.  When  the 
intoxication  is  less  severe,  the  paralysis  may  remain  for  some 
time  limited  to  a  group  of  muscles. 

Animals  which,  like  rats  and  mice,  are  not  affected  by  the 
inoculation  of  the  bacilli,  show  the  same  resistance  to  the  fil- 
tered poison. 

Is  the  diphtheritic  poison  an  alkaloid  or  a  diastase  ?  While 
not  yet  prepared  to  definitively  answer  that  question,  the  au- 
thors state  that  the  activity  of  the  toxic  matter  is  greatly 
diminished  by  heat,  and  also  by  exposure  to  the  air — circum- 
stances which  favor  the  latter  hypothesis. 

The  first  part  of  a  study  of  the  etiology  of  diphtheria1  by  Dr. 
T.  M.  Prudden,  which  is  very  important  both  from  the  com- 
pleteness and  precision  of  its  methods  of  investigation  and  the 
definiteness  of  its  results,  appears  just  as  this  work  is  going 
to  press.  It  consists  of  bacterial  examinations,  morphological 
and  by  cultures,  in  twenty-four  fatal  cases  of  diphtheria.  In 
most  of  the  morphological  examinations  micrococci,  usually 
in  large  numbers,  were  found  in  all  parts  of  the  false  mem- 
branes, including  their  deeper  layers,  in  the  necrosed  epithe- 
lium, in  some  instances  in  the  lymph-spaces  of  the  mucosa  and 

1 "  On  the  Etiology  of  Diphtheria,"  by  T.  Mitchell  Prudden,  M.D., 

American  Journal  of  the  Medical  Sciences,  April,  1889. 


264:  diphtheria;  its  nature  and  treatment. 

submucosa,  and  in  one  instance  extending-  deeply  into  the  sub- 
mucous tissues,  accompanied,  when  abundant,  with  necrosis. 
The  cocci  in  the  false  membrane  were  accompanied  by  other 
bacteria,  among*  which  in  some  of  the  cases,  are  mentioned 
various  forms  of  bacilli ;  but  these  are  usually  described  as  few, 
scattering,  and  limited  to  the  more  superficial  portions  of  the 
false  membranes.  In  two  exceptional  cases  micrococci  were 
wanting,  and  bacilli  were  numerous. 

In  most  of  the  cultures  from  the  false  membranes  strepto- 
cocci, usually  in  great  numbers,  and,  in  some  instances,  in 
nearly  pure  cultures,  appeared.  The  other  bacteria,  including 
the  various  forms  of  bacilli,  were  not  uniformly  present  and 
were,  in  most  cases,  in  much  smaller  numbers.  In  the  two  ex- 
ceptional instances  already  referred  to  (in  which  the  larynx 
and  trachea  were  lined  with  dense  firm  false  membrane,  but 
there  was  no  false  membrane  in  the  pharynx)  no  colonies  of 
streptococci  appeared  in  the  cultures,  but  "short,  stout,  round- 
encl  bacilli "  were  numerous.  In  seven  cases,  cultures  of  strep- 
tococci, in  most  instances  pure,  were  developed  from  one  or 
more  of  the  internal  organs,  namely  the  kidneys,  the  spleen, 
the  lungs  and  the  liver. 

These  observations,  as  is  remarked  by  the  author,  seem  to 
point  to  the  importance  of  the  streptococcus.  A  study  by  him 
of  its  characters  and  life-history  will  be  subsequently  published. 


INTUBATION  IN  CROUP 


AND    OTHEK 


ACUTE  AND   CHROHIO  FORMS    OF    STE- 
NOSIS  OF  THE  LARYNX. 


The  earliest  record  of  catheterization  of  the  larynx  is  found 
in  the  writings  of  Hippocrates,  who  suggested  that  in  cases  of 
inflammatory  cynanche,  cannulas  should  he  carried  into  the 
throat  along  the  jaws  so  that  air  might  he  drawn  into  the 
lungs. 

This  suggestion  was  adopted  by  many  of  the'  ancient  phy- 
sicians until  the  discovery  of  bronchotomy  (tracheotomy)  by 
Asclebiades  about  a  century  before  the  Christian  era.  Cathe- 
terization was  then  lost  sight  of  until  1780,  when  it  was  revived 
by  Chaussier,  who  proposed  the  use  of  a  laryngeal  tube  in  the 
asphyxia  of  the  new-born  and  to  overcome  obstruction  due  to 
disease. 

Several  attempts  were  made  about  this  time  to  retain  a 
catheter  in  the  larynx  but  were  unsuccessful  owing  to  the 
sensibility  of  the  parts. 

Dissault  in  ]  801,  and  many  others  after  his  time,  appear  to 
have  had  some  measure  of  success  in  the  treatment  of  laryn- 
geal stenosis  by  this  method,  particularly  in  adults.     But  the 


266  INTUBATION   IN   CROUP   AND   OTHER 

retention  of  one  end  of  a  tube  in  the  trachea,  while  the  other 
protrudes  either  from  the  mouth  or  nose,  is  obviously  imprac- 
ticable in  children. 

The  first  and  only  attempt  before  my  own  to  use  a  short 
tube  in  the  larynx,  that  would  allow  the  epiglottis  to  close  over 
it,  was  made  by  Bouchut  in  1858.  His  failure  after  a  limited 
trial  was  due  principally  to  his  extravagant  claims  for  the 
new  operation  as  a  substitute  for  opening  the  trachea  before 
he  had  any  results  to  show,  and  to  his  bitter  denunciation  of 
Trousseau's  pet  operation,  tracheotomy,  which  Bouchut 
claimed  had  considerably  increased  the  death  rate  from  croup 
instead  of  diminishing  it.  Personal  enmities  therefore  played 
a  more  important  part  than  the  merits  or  demerits  of  the 
new  procedure  in  determining  the  final  decision  of  the  Acad- 
emy against  it. 

A  very  complete  bibliography  of  this  subject  under  the 
titles  of  catheterization  of  the  larjmx,  tubage  of  the  glottis, 
and  intubation  will  be  found  in  a  paper  by  Dr.  Dillon  Brown 
in  the  Transactions  of  the  9th  International  Medical  Congress, 
section  on  Diseases  of  Children. 


DESCRIPTION   OF   INTUBATION   INSTRUMENTS. 

A  set  of  instruments  for  children,  under  the  age  of  puberty, 
consists  of  six  tubes  (1)  of  different  sizes  and  varying  in  length 
from  one  and  a  half  to  two  and  a  half  inches;  an  introducer, 
(fig.  2),  an  extractor,  (fig.  3),  a  mouth  gag  (fig.  4),  and  scale 
of  years  (fig.  5).  Each  tube  is  provided  with  a  separate  ob- 
turator for  the  purpose  of  attaching  it  to  the  introducer  and, 
by  projecting  somewhat  beyond  the  distal  extremity,  produces 
a  probe-point  which  prevents  injury  to  the  tissues  on  the  de 
tachment  of  pseudo-membrane  during  the  operation.  The 
numbers  on  the  scale  (fig.  5)  represent  years,  and  indicate  ap- 
proximately the  ages  for  which  the  corresponding  tubes  are 
suitable. 


FORMS   OF   STENOSIS   OF   THE   LARYNX. 


267 


Fig.  1. 


Fig.  2. 


Fig.  3. 


G.TIEMANNKO. 


■HI 


268  INTUBATION    IN    CEO  UP    AND    OTHER 

The  smallest  tube  when  applied  to  the  scale  will  reach  the 
line  marked  1,  and  is  suitable  for  children  of  one  year  and 
under.  In  children  of  fifteen  months,  small  for  age,  this  size  is 
preferable  to  the  two-year  size,  and  it  can  be  used  at  eighteen 
months,  or  even  two  years,  without  the  slightest  danger  of 
passing  through,  but  is  apt  to  be  coughed  out.  The  next  size, 
which  reaches  the  line  on  the  scale  marked  2,  is  intended  for 
children  between  one  and  two  years,  but  can  also  be  used  at 
two  and  a  half  or  three  years  with  objection  referred  to  above. 
The  third  size,  marked  3-4  on  the  scale,  should  be  used  in  cases 
over  two  and  up  to  four  years,  and  so  on.  The  female  larynx 
in  children  as  well  as  in  adults  is  smaller  than  the  male,  which 
should  also  be  considered  in  selecting  the  proper  tube  to  be 
used. 

Owing  to  the  rapid  increase  in  the  size  of  the  larynx  at  the 
age  of  puberty,  the  string  should  be  left  attached  to  the  largest 
tube  when  used  after  this  period  of  life. 

In  measuring  the  tubes  to  select  the  proper  size,  the  heads 
are  of  course  included. 

The  tube  indicated  by  the  scale  of  years,  is  never  too  large 
to  pass  through  any  form  of  acute  stenosis,  except  in  rare 
cases  of  extreme  subglottic  infiltration  of  the  mucous  mem- 
brane, in  which  a  smaller  size  may  have  to  be  used.  Fig.  6 
shows  a  specimen  of  this  kind,  with  cross  section  through  cri- 
coid cartilage  less  than  a  quarter  of  an  inch  below  the  vocal 
cords.  To  pass  the  proper  sized  tube  through  a  stricture  of 
this  nature,  surrounded  as  it  is  by  an  unyielding  cartilaginous 
ring,  requires  more  or  less  force,  and  these  are  the  only  cases 
in  which  it  is  justifiable. 

Fig.  7  represents  the  normal  lumen  of  the  subglottic 
division  of  the  larynx  from  a  child  of  the  same  age,  and  Fig. 
8  a  section  from  the  trachea  of  the  same  showing  the  great 
difference  in  the  caliber  of  the  air  passage  at  these  points. 

I  have  used  the  5-7  tube  at  two  years  of  age  either  to  ob- 
tain the  benefit  of  the  increased  length  or  larger  head,  and 


FORMS    OF    STENOSIS    OF    THE    LARYNX. 


269 


this  can  be  adopted  where  there  is  pseudo-membrane  produc- 
ing- obstruction  at  the  lower  extremity  or  swollen  tissue  over- 
lapping the  head  of  the  smaller  tube.  Greater  interference 
with  deglutition  and  the  danger  of  ulceration  if  the  tube  be 
long  retained,  are  the  only  objections  to  this  plan.  All  such 
indications  could  be  met  by  a  greater  variety  of  tubes. 

When  the  proper  tube  for  the  case  to  be  operated  on  has 
been  selected,  a  strong  thread  of  silk,  or  linen  is  passed  through 
the  small  eyelet  intended  for  this  purpose,  and  the  ends  tied 
together.     Braided  silk  is  the  best,  as  it  will  not  unravel  if  one 


Fig.  6. 


Fig.  7. 


Fig.  8. 


strand  should  cut  and  thus  block  the  opening,  which  sometimes 
happens  with  the  twisted  variety.  Leaving  this  string  too 
short  has  been  the  cause  of  much  annoyance  to  several  opera- 
tors and  alarm  to  the  friends  of  the  patient  by  allowing  the 
tube,  when  placed  in  the  oesophagus,  to  slip  into  the  stomach, 
which  it  quickly  does  if  the  malposition  be  not  recognized. 
This  accident  can  always  be  avoided  by  leaving  the  thread 
long  enough  to  reach  the  stomach  and  still  leave  a  portion 
protruding  from  the  mouth.  The  obturator  is  then  screwed 
firmly  on  the  introducer  to  prevent  the  tube  from  rotating 
while  being  inserted,  which  would  be  liable  to  bring  the  pos- 
terior projecting  portion  of  the  flange  under  the  epiglottis. 


270  INTUBATION   IN   CROUP   AND    OTHER 

The  upper  end  of  the  tube  is  curved  backward  and  the  shoulder 
removed  anteriorly  to  allow  greater  freedom  to  the  epiglottis 
during-  the  act  of  swallowing. 

The  long  diameter  of  the  tube  when  applied  and  ready  for 
use,  should  be  in  a  line  with  the  handle  of  the  introducing  in- 
strument. If  found  to  turn  too  far,  as  usually  happens  after 
considerable  use,  a  washer  of  writing  paper,  of  one  or  more 
thicknesses,  is  sufficient  to  hold  the  obturator  in  the  proper 
position.  If  the  lower  extremity  of  the  obturator  does  not 
project  far  enough  beyond  the  tube  to  make  a  smooth  blunt 
point,  it  will  be  found  that  the  thread  is  too  thick  or  is  not  in 
the  groove  corresponding  to  the  hole  in  the  tube.  In  most  of 
the  instruments  made  at  present,  the  eyelet  is  in  the  left  an- 
terior part  of  the  shoulder,  which  removes  this  difficulty. 

Indications  for  Intubation. — The  indications  for  intuba- 
tion are  the  same  as  for  tracheotomy.  There  is  no  reason 
why  one  should  be  performed  earlier  than  the  other.  The  be- 
ginning of  the  third  or  suffocative  stage  is  the  proper  time  to 
interfere.  This  is  marked  by  more  or  less  sinking  in  of  the 
yielding  portions  of  the  chest,  lower  ribs  and  sternum,  episternal 
notch,  and  supra-clavicular  regions  with  inspiration.  It  means 
simply  that  air  cannot  gain  admission  to  the  lungs  in  sufficient 
quantity  to  fill  the  partial  vacuum  created  by  the  expansion 
of  the  chest,  and  the  walls  recede  under  the  weight  of  the  at- 
mosphere. It  is  more  marked  in  very  young  or  rachitic  chil- 
dren owing  to  the  greater  elasticity  of  the  ribs.  But  it  should 
be  remembered  that  this  symptom  is  not  peculiar  to  stenosis 
of  the  larynx  and  trachea,  as  it  is  produced  to  a  lesser  degree 
by  obstruction  in  any  part  of  the  respiratory  tract  that  inter- 
feres with  the  free  inflation  of  the  lungs.  It  is  found  in  capil- 
lary bronchitis,  extensive  deposits  of  pseudo-membrane  in  the 
bronchi,  atelectasis,  and  to  some  extent  even  in  broncho-pneu- 
monia. Recessions  at  the  root  of  the  neck  are  more  significant 
than  those  below,  as  the  violent  contractions  of  the  diaphragm 
aid  in  drawing-  in  the  free  border  of  the  ribs  and  sternum. 


FORMS    OF   STENOSIS   OF   THE  •  LARYNX.  271 

.  When  recessions  are  marked  there  is  little  or  no  respira- 
tory murmur  over  the  posterior  portion  of  the  chest,  but  this 
symptom  is  not  always  available  owing-  to  the  laryngeal 
stridor. 

Atelectasis  with  excessive  quantity  of  blood  in  the  lungs, 
as  would  naturally  be  expected,  is  the  result  of  death  from  ob- 
struction in  the  larynx,  but  there  are  exceptions  to  this  rule, 
and  these  organs  are  occasionally  found  distended  with  air 
and  containing  less  than  the  normal  amount  of  blood.  This 
acute  general  emphysema,  which  produces  bulging  of  the 
parts  that  usually  recede,  is  caused  by  greater  impediment  to 
expiration  than  inspiration,  and  air  accumulates  in  the  lungs 
in  the  same  manner  as  in  spasmodic  asthma.  It  is  not  com- 
mon in  croup,  but  is  worth  remembering.  It  is  also  occasion- 
ally found  in  capillary  bronchitis. 

The  downward  movement  of  the  larynx  with  inspiration  is 
pathognomonic  of  serious  obstruction  in  this  organ,  and  is  also 
the  result  of  atmospheric  pressure,  the  air  being  prevented 
from  entering  with  sufficient  rapidity  to  fill  the  partial  vacuum 
below.  It  is  readily  detected  in  adults,  but  not  so  in  children, 
owing  to  the  deeper  situation  of  the  larynx  in  the  latter. 

This  symptom  is  not  present  in  stenosis  of  the  trachea, 
owing  to  the  great  elasticity  of  this  tube,  which  permits  of 
considerable  motion  on  itself  without  displacing  the  larynx, 

Abiding  cyanosis  is  too  late  a  symptom  to  wait  for,  and, 
besides,  it  is  uncertain,  as  fatal  obstruction  may  exist  in  the 
glottis  with  extreme  pallor  of  the  surface.  This  pallor  of 
asphyxia  is  produced  by  the  excessive  quantity  of  blood  drawn 
into  and  stored  in  the  lungs  by  the  cupping-glass  action  of  in- 
spiration when  the  air  is  almost  excluded.  The  blood  in  the 
cutaneous  capillaries  is  thus  reduced  to  a  minimum,  and  this, 
although  highly  charged  with  carbonic  acid,  only  serves  to 
increase  the  paleness,  on  the  principle  that  the  addition  of  a 
little  blue  makes  a  clearer  white. 

The  temporary  cyanosis  which  comes  and  g-oes  with  the 


272  INTUBATION   IN    CROUP   AND   OTHER 

paroxysmal  dyspnoea  of  the  second  stage  of  croup  is  of  no 
particular  significance. 

Children  seldom  remain  long  in  one  position  when  suffering 
severely  from  want  of  breath,  and  continued  restlessness,  if 
consciousness  be  unimpaired,  is  therefore  an  important  indica- 
tion that  it  is  time  to  afford  relief. 

As  far  as  the  necessity  for  intubation  is  concerned,  it  mat- 
ters little  as  to  the  nature  of  the  obstruction  provided  it  be  in 
the  larynx  and  not  a  foreign  body.  It  may  be  croup,  simple 
laryngitis,  oedema  of  the  glottis,  paralysis,  spasm,  or  even  a 
neoplasm.  In  the  latter  it  will  tide  over  the  immediate  danger 
of  asphyxia,  and  leave  more  breathing  room  to  facilitate  the 
radical  operation. 

Method  of  Operating. — The  nurse  or  person  who  holds  the 
child  should  be  seated  on  a  solid  chair  with  low  back,  and  the 
patient  placed  on  the  lap  with  head  resting  on  left  shoulder  of 
nurse  in  order  to  leave  the  gag  free.  The  hands  can  either 
be  held,  or,  still  better,  secured  by  the  sides  hj  a  towel  or  sheet 
passed  around  the  body  and  left  in  that  position  until  the  tube 
is  inserted  and  the  string  removed.  Fastening  the  hands  in 
front  of  the  chest  or  thick  garments  in  the  same  location  ren- 
ders it  more  difficult  to  depress  the  handle  of  the  introducer 
sufficiently  to  carry  the  tube  over  the  dorsum  of  the  tongue. 

The  gag  (fig.  4)  is  then  inserted  well  back  behind  or  be- 
tween the  teeth  in  the  left  angle  of  the  mouth  and  opened 
widely,  care  being  taken  not  to  do  it  too  suddenty  or  to  use 
too  much  force.  In  children  who  have  not  at  least  one  bi- 
cuspid on  the  left  side,  the  gag  should  not  be  used,  as  it  slips 
forward  on  the  gums,  and,  besides  being  in  the  way,  is  liable  to 
injure  the  incisor  teeth.  There  is  little  difficult}^  in  these  cases 
in  keeping  the  mouth  sufficiently  open  with  the  finger,  if  car- 
ried far  enough  to  the  patient's  right  to  be  out  of  range  of  the 
front  teeth.  Allowing  the  child  to  compress  the  finger  be- 
tween the  gums  for  a  few  seconds  until  the  jaws  relax,  before 
carrying  it  into  the  fauces,  avoids  the  necessity  for  using  force. 


FORMS    OF   STENOSIS   OF   THE    LARYNX. 


273 


The  Denharclt  gag,  which  is  the  one  shown  in  the  cut,  holds 
better  than  the  one  originally  devised  by  the  author,  the 
handle  of  which  projects  downward  and  is  liable  to  be  knocked 


Fig.  9,  shows  the  positions  of  assistant,  nurse  and  patient  with  gag  in  position. 

out  of  place  by  coming  in  contact  with  the  shoulder  in  the 

movements  of  the  child's  head. 

An  assistant  stands  behind  the  patient  and  holds  the  head 

firmly  by  placing  one  hand  on  either  side,  and  at  the  same 

time  slightly  elevates  the  chin.     The  person  who  holds  the 
18 


274  INTUBATION   IN   CROUP   AND   OTHER 

head,  if  without  any  experience,  should  be  requested  not  to 
touch  the  gag,  as  this,  if  properly  placed,  retains  its  hold  by 
the  pressure  of  the  teeth. 

The  operator  stands  in  front  of  the  patient  holding-  the 
introducer  lightly  between  the  thumb  and  fingers  of  the  right 
hand,  the  thumb  resting  on  the  upper  surface  of  the  handle 
just  behind  the  knob  that  serves  to  detach  the  tube  and  the 
index  finger  in  front  of  the  trigger  support  underneath. 

Held  in  this  manner  it  is  impossible  to  use  force  enough  to 
make  a  false  passage,  while  if  firmly  grasped  in  the  hand  the 
beginner  may,  unconsciously,  exert  sufficient  force  to  lacerate 
the  tissues. 

The  index  finger  of  the  left  hand  is  carried  well  down  in 
the  pharynx  or  beginning  of  oesophagus  and  then  brought 
forward  in  the  median  line,  raising  and  fixing  the  epiglottis, 
while  the  tube  is  guided  along  beside  it  into  the  larynx.  If 
any  difficulty  is  experienced  in  locating  the  epiglottis,  it  is 
better  to  search  for  the  cavity  of  the  larynx,  a  cul  de  sac  into 
which  the  tip  of  the  finger  readily  enters  and  which  cannot  be 
mistaken  for  anything  else.  Once  in  this  cavity  the  epiglottis 
must  be  in  front  of  the  finger  and  the  latter  is  then  raised  and 
pressed  towards  the  patient's  right  to  leave  room  for  the  tube 
to  pass  beside  it.  The  distal  extremity  of  the  tube  should  be 
kept  in  contact  with  the  finger,  and  even  directing  it  a  little 
obliquely  towards  the  right  side  of  the  larynx  is  necessary  to 
get  inside  the  left  ary-epiglottic  fold,  especially  in  very  young 
children. 

The  handle  of  the  introducer  is  held  close  to  the  patient's 
chest  in  the  beginning  of  the  operation,  and  rapidly  raised  as 
soon  as  the  lower  end  of  the  tube  has  passed  behind  the  epi- 
glottis, otherwise  it  will  slip  over  the  larynx  into  the  oesopha- 
gus. 

Some  operators  hold  the  introducing  instrument  in  the 
horizontal  position  until  the  tube  is  well  back  in  the  fauces, 
and  then  swing  it  around  to  the  middle  line  and  complete  the 


FORMS    OF    STENOSIS    OF    THE    LARYNX.  275 

operation  in  the  usual  manner.  The  beginner  is  liable  to  for- 
get the  latter  movement,  which  is  the  only  objection  to  this 
plan. 

As  soon  as  the  cannula  is  inserted  it  is  detached  by  press- 
ing forward  the  button  on  the  upper  surface  of  the  handle 
with  the  thumb,  while  counter-pressure  is  made  with  the  index 
finger  on  the  trigger  beneath.  In  removing  the  obturator — the 
joint  in  the  shank  of  which  is  intended  to  facilitate  this  part 
of  the  operation — the  movements  required  for  insertion  are 
reversed.  To  prevent  the  tube  from  being  also  withdrawn, 
the  finger  must  be  kept  in  contact  with  its  shoulder  either  on 
the  side  or  posteriorly. 

The  tube  should  be  carried  well  down  in. the  larynx  before 
detaching  it,  otherwise  the  lower  aperture  will  be  left  open 
and  liable  to  strip  off  pseudo-membrane  as  it  is  subsequent^ 
pushed  home  with  the  finger. 

The  gag  is  removed  as  soon  as  the  tube  is  in  place,  but  the 
string  is  allowed  to  remain  long  enough  to  be  certain  that  the 
dyspnoea  is  relieved  and  that  no  loose  membrane  exists  in 
the  lower  portion  of  the  trachea.  In  some  cases  the  presence 
of  the  thread  is  desirable  because  it  excites  more  cough,  which 
is  necessary  to  expel  accumulated  secretions  and  to  inflate 
any  collapse  of  the  lungs  that  may  have  taken  place.  In  re- 
moving the  string  the  finger  must  be  re-inserted  to  hold  the 
tube  down,  but  the  gag  is  rarely  necessary,  as  children  old 
enough  to  understand  readily  open  the  mouth  for  this  purpose. 

In  withdrawing  the  tube  the  child  is  held  in  the  same  posi- 
tion, and  the  extractor  is  guided  along  the  side  of  the  finger, 
which  is  brought  in  contact  with  the  head  of  the  cannula  and 
then  pressed  toward  the  patient's  right  in  order  to  uncover 
the  aperture  and  allow  the  instrument  to  enter  in  a  straight 
line.  Dr.  Waxham  and  others  pass  the  extractor  under  the 
finger,  that  is,  between  it  and  the  epiglottis,  and  intubate  in 
the  same  manner.  I  have  not  tried  this  method  and  cannot 
therefore  express  an  opinion  as  to  its  merits.     No  attempt  at 


276  INTUBATION   IN   CROUP   AND    OTHER 

extraction  should  be  made  until  the  head  of  the  tube  is  felt, 
which  can  always  be  done  no  matter  how  extensive  the  swell- 
ing- of  the  epiglottis  and  ary-epiglottic  folds  may  be.  Many 
times  the  tissues  have  been  lacerated  by  repeated  attempts  to 
remove  a  tube  from  the  larynx  which  was  somewhere  else, 
most  likely  in  the  bed  or  ejected,  unobserved,  into  a  vessel 
during  the  act  of  vomiting,  and  thrown  out. 

The  tubal  cough  is  characteristic,  and  when  once  heard 
cannot  be  mistaken,  but  it  sometimes  assumes  a  hoarse  or 
croupy  quality  from  loose  membrane  below  or  overlapping 
tissues  above,  and  in  such  cases  the  presence  of  the  tube  must 
be  demonstrated  by  the  sense  of  touch. 

To  place  a  tube  in  the  larynx  of  a  struggling,  choking  child, 
in  the  brief  space  of  time  that  is  compatible  with  safety,  is  a 
difficult  thing  to  do,  and  should  not  be  attempted,  except  in 
case  of  emergency,  without  previous  practice  on  the  cadaver. 
Those  only  who  possess  an  extraordinary  amount  of  dexterity 
combined  with  coolness  will  succeed  without  such  practice. 
The  operator  has  so  many  things  to  think  of  and  so  many 
movements  to  make  with  both  hands,  all  in  a  few  seconds, 
that  unless  he  have  had  sufficient  practice  to  make  some  of 
these  movements  to  a  certain  extent  automatic,  he  cannot 
operate  with  safety  to  his  patient  or  with  credit  to  himself. 
The  epiglottis  must  be  found,  raised  and  held  in  this  position, 
as  the  tube  is  glided  down  in  contact  with  the  finger,  other- 
wise the  operator  does  not  know  where  it  is ;  it  must  be  slipped 
off  at  the  right  moment  and  held  down  while  the  obturator  is 
withdrawn,  all  to  be  accomplished  in  ten  seconds  or  less.  It 
is  this  important  element  of  time,  therefore,  that  converts  an 
otherwise  simple  operation  into  a  very  difficult  one. 

Practice  on  the  cadaver  is  within  the  reach  of  compara- 
tively few,  but  a  larynx  from  any  of  the  smaller  animals  can 
be  procured  by  every  one;  and  repeated  practice  on  this,  placed 
upright  in  the  neck  of  a  bottle  or  other  convenient  receptacle, 
is  an  excellent  substitute.     I  have  always  advised  those  to 


FORMS    OF    STENOSIS    OF    THE    LARYNX.  277 

whom  I  have  given  practical  instruction  on  this  subject  to 
continue  this  kind  of  practice  at  frequent  intervals,  because  a 
few  lessons  on  the  cadaver  are  not  sufficient  to  insure  pro- 
ficiency and  have  only  the  advantage  over  this  method  of 
learning  to  operate  in  the  same  small  space  that  exists  in  the 
living  subject. 

The  larynx  should  be  placed  in  the  same  position  it  occu- 
pied in  the  body,  the  operator  going  through  the  different 
steps  of  inserting  and  removing  the  tube  solely  by  the  sense  of 
touch  without  watching  his  own  movements,  and  when  any 
obstacle  is  encountered  holding  the  introducer  or  extractor  in 
position  until  he  investigate  the  cause  of  the  difficulty.  An 
hour's  rehearsal  of  this  kind  just  before  going  to  remove  a 
tube  from  a  patient  is  of  the  greatest  advantage,  and  gives  an 
amount  of  confidence  that  contributes  largely  to  a  successful 
result. 

I  have  found  the  greatest  difficulty  in  overcoming  the 
habit,  always  adopted  by  beginners,  of  placing  the  thumb  on 
the  lever  of  the  extractor  while  guiding  it  into  the  tube.  The 
most  expert  operator  cannot  do  this  without  running  the  risk 
of  unconsciously  making  slight  pressure  too  soon,  thus  sepa- 
rating the  nibs,  which  are  very  liable  to  seize  some  of  the  tis- 
sues as  they  close,  besides  otherwise  interfering  with  the 
success  of  the  operation.  The  thumb  should  be  constantly 
"  occupied  by  placing  it  on  the  upper  surface  of  the  handle  until 
the  instrument  is  introduced,  then  transferred  to  the  lever  and 
continuous  pressure  kept  up  while  the  tube  is  being  removed. 
Intermittent  pressure  will  allow  the  tube  to  drop  off  into  the 
pharynx  and  possibly  to  enter  the  stomach. 

Intubation  performed  by  an  expert  is  an  operation  that 
may  be  witnessed  by  the  most  sympathetic  mother  without 
material  shock  to  her  nervous  system,  while  in  the  hands  of 
the  novice  there  are  few  operations  more  repulsive  even  to  the 
uninterested  spectator.  A  small  percentage  of  the  amount 
of  practice  required  to  make  a  good  marksman,  billiard -player, 


278  INTUBATION   IN    CROUP   AND    OTHER 

etc.,  if  expended  in  the  manner  above  indicated,  would  impart 
sufficient  dexterity  to  obtain  the  best  results  with  intubation, 
and  at  the  same  time  avoid  a  great  deal  of  unnecessary  suffer- 
ing- and  some  loss  of  life  also. 

The  proper  time  for  removing  the  tube  from  the  larynx 
will  depend  on  the  age  of  the  patient,  the  character  of  the  dis- 
ease, whether  of  slow  or  rapid  development,  and  the  progress 
of  the  case.    . 

In  one  hundred  and  fifty-eight  recoveries  from  croup,  in 
which  the  exact  time  was  recorded,  the  average  retention  of 
the  tubes  amounted  to  five  days  and  two  hours.  In  my  own 
forty-nine  recoveries,  the  longest  time  a  tube  was  retained 
was  fourteen  days,  and  the  shortest  time  in  which  pseudo- 
membrane  was  demonstrated  to  have  been  present  was  four- 
teen hours. 

The  younger  the  patient,  as  a  rule,  the  longer  the  tube  will 
be  required.  In  children  under  two  years  of  age  it  is  better  to 
leave  it  in  seven  days. 

When  the  disease  has  developed  slowly,  and  has  therefore 
run  a  greater  part  of  its  course  before  calling  for  operative 
interference,  the  tube  can  be  dispensed  with  earlier — sometimes 
as  soon  as  the  second  or  third  day. 

If  the  case  be  at  such  a  distance  as  to  render  it  impossible 
to  reach  it  in  a  reasonable  time,  it  is  safer,  if  progressing  fav- 
orably, to  leave  the  tube  in  position  for  seven  or  eight  days, 
and  the  exceptions  are  few  in  which  it  will  be  necessary  to  re- 
insert it  after  this  time. 

The  tube  should  always  be  removed  on  the  recurrence  of 
severe  dyspnoea,  because  it  is  sometimes  impossible  to  ascer- 
tain with  certainty  whether  it  be  partially  obstructed  or  not. 
The  best  evidence  to  the  contrary  is  a  good  respiratory 
murmur  or  numerous  rales  over  the  lower  posterior  portion 
of  the  lungs.  Even  under  these  circumstances  I  have  occa- 
sionally found  the  lumen  of  the  tube  seriously  encroached 
upon  by  firmly  adherent  secretions. 


FOEMS    OF    STENOSIS    OF    THE    LARYNX.  279 

In  one  case  of  this  kind,  complicated  with  extensive  broncho- 
pneumonia to  which  the  dyspnoea  was  attributed,  the  tube 
when  removed  appeared  to  be  completely  occluded  through  its 
whole  length,  3ret  an  opening  must  have  existed  in  it  some- 
where. Had  I  found  it  in  this  condition  on  its  removal  after 
death  I  would  certainly  have  attributed  the  fatal  result  to 
this  cause. 

Such  cases — and  I  have  seen  several  similar  ones — prove 
that  sufficient  air  to  sustain  life  can  be  admitted  through  an  ex- 
tremely small  opening.  The  adhesion  of  tenacious  secretions 
to  the  inside  of  the  tube  is  more  liable  to  occur  in  very  young 
children,  owing  to  their  comparatively  feeble  power  of  cough- 
ing, and  for  the  same  reason  they  are  more  prone  to  pulmonary 
complications.  In  older  children  who  are  strong  and  can  be 
induced  to  cough  vigorously  such  accumulations  are  rare. 
They  are  also  favored  by  a  high  temperature,  which  is  usually 
attended  with  scanty  secretion,  and  particularly  if  at  the  same 
time  both  nostrils  are  occluded,  necessitating  mouth  breath- 
ing. 

I  have  never  known  any  serious  diminution  of  the  lumen  of 
the  tube  to  occur  suddenly  from  secretions.  It  is  a  process 
that  usually  requires  at  least  many  hours  and  sometimes  days. 

The  development  of  a  high  temperature,  especially  if  accom- 
panied with  any  considerable  amount  of  bronchitis,  on  the  third 
or  fourth  day,  is  a  sufficient  reason  for  removing  the  cannula, 
as  it  can  sometimes  be  permanently  dispensed  with  as  early 
as  this,  and  even  if  left  out  for  only  a  few  hours  without  urgent 
dyspnoea,  is  of  great  benefit,  as  it  affords  an  opportunity  to 
unload  the  bronchi  of  secretions  by  permitting  complete  closure 
of  the  glottis  and  thus  giving  full  effect  to  the  act  of  cough- 
ing. In  those  cases  that  refuse  nourishment  after  intubation 
or  that  cannot  be  induced  to  take  a  sufficient  quantity,  it  is 
useless  to  remove  the  tube  for  the  purpose  of  feeding,  unless  it 
have  been  in  long  enough  to  give  some  reasonable  hope  that 
its  further  use  will  not  be  necessary,  as  it  is  difficult  to  con- 


280  INTUBATION    IN    CROUP    AND    OTHER 

vince  children  for  some  time  that  they  can  swallow  any  better 
than  before. 

If  no  dyspnoea  recur  in  half  an  hour  after  the  extraction  of 
the  tube,  it  is  safe  to  leave  the  patient,  if  not  at  too  great  a 
distance  to  be  reached  within  two  or  three  hours. 

Accidents  and  Dangers  of  Intubation. — The  most  serious 
of  the  accidents  incident  to  this  operation  is  apncea  from  pro- 
longed attempts  to  introduce  the  tube.  This  can  be  avoided 
only  by  acquiring-  thorough  familiarity  with  the  use  of  the  in- 
struments in  the  manner  already  pointed  out.  The  beginner, 
unless  he  possess  an  unusual  amount  of  coolness,  is  liable  to 
forget  that  while  his  finger  is  in  the  throat,  the  patient  cannot 
breathe,  and  that  a  fatal  asphyxia  may  be  produced  in  a  very 
few  seconds.  Ten  seconds  is  the  longest  time  that  should  be 
occupied  in  each  attempt,  if  the  child  be  suffering  from  urgent 
dyspnoea  at  the  time.  If  the  finger  be  then  removed  from  the 
mouth,  and  the  patient  be  given  a  chance  to  get  its  breath, 
many  failures  to  properly  place  the  tube  can  be  made  without 
danger. 

The  expert  seldom  requires  more  than  five  seconds  to  com- 
plete the  operation,  except  in  difficult  cases,  such  as  a  very 
small  mouth  and  throat,  marked  increase  in  the  size  of  the 
tonsils,  especially  if  chronic,  extreme  tumefaction  of  the  epi- 
glottis and  ary-epiglottic  fold  which  changes  or  obliterates 
the  usual  landmarks,  and  the  struggles  and  resistance  some- 
times offered  by  older  children  when  intractable.  In  the  latter, 
although  I  have  never  had  to  resort  to  it,  the  administration 
of  an  anaesthetic  would  be  less  injurious  than  the  exhaustion 
and  cyanosis  induced  by  a  prolonged  struggle  without  it. 

If  the  tube  has  once  passed  on  the  outside  of  the  larynx, 
and  this  is  recognized  before  it  is  detached  from  the  obturator, 
it  is  useless  to  try  to  rectify  the  position  without  first  depress- 
ing the  handle  of  the  introducer  as  in  the  beginning  of  the 
operation,  because  owing'  to  the  length  of  the  tube  the  palate 
arrests  the  upward  movement  before  the  distal  extremity 
reaches  the  level  of  the  glottic  opening. 


FORMS   OF    STENOSIS    OF   THE    LARYNX.  281 

In  croup  the  ventricles  of  the  larynx  are  usually  obliterated 
by  swelling-  of  the  tissues  and  covered  over  by  the  pseudo- 
membrane,  and  therefore  seldom  offer  any  obstacle  to  the 
passage  of  the  tube  on  the  first  introduction;  but  when  the 
stenosis  persists  longer  than  usual  and  reintroduction  becomes 
necessary,  it  is  well  to  remember  that  this  may  be  a  source  of 
obstruction.  The  tube  once  having  entered  a  ventricle,  a 
moderate  amount  of  force  is  all  that  is  necessary  to  make  a 
false  passage.  I  have  known  this  accident  to  occur  when  the 
operator  was  unconscious  of  having  used  any  force  whatever. 

If  the  patient's  head  be  thrown  too  far  back,  the  tube  may 
also  be  arrested  by  coming  in  contact  with  the  anterior  wall 
of  the  larynx  or  trachea. 

Pushing  down  membrane  before  the  tube  is  the  most  seri- 
ous of  the  unavoida  ble  accidents  attending  this  operation. 

It  has  happened  in  only  three  of  my  own  two  hundred  and 
nine  cases  of  croup,  so  far  intubated,  on  the  first  introduction. 
In  two  of  these  apncea  was  complete,  and  the  tubes  had  to  be 
removed  immediately  and  were  followed  by  complete  casts  of 
the  trachea.  In  the  third  case  expiration  only  was  seriously 
obstructed,  and  the  tube  was  allowed  to  remain  about  ten 
minutes  in  order  to  allow  the  lungs  to  become  fully  inflated, 
and  to  make  more  room  in  the  glottis  for  the  passage  of  the 
pseudo-membranous  mass.  As  traction  was  made  on  the 
thread,  the  patient  was  directed  to  cough,  and  with  the  same 
result  as  in  the  others. 

In  none  of  these  cases  was  the  dyspnoea  relieved  in  the 
least  by  the  rejection  of  the  membranes,  and  the  immediate 
reintroduction  of  the  tube  was  necessary  in  each.  Had  the  ob- 
struction existed  in  the  trachea,  the  relief  would  have  been 
prompt,  but  it  was  in  the  glottis,  where  the  fibrinous  exuda- 
tion remains  long  adherent  and  where  the  principal  cause  of 
the  stenosis  is  the  infiltration  of  the  mucous  membrane  and 
underlying  tissues  and  not  the  film  of  adventitious  material 
on  the  surface. 


282  INTUBATION   IN   CROUP   AND    OTHER 

The  trachea  being-  so  much  larger  than  is  required  for  the 
free  passage  of  air  to  and  from  the  lungs  that  no  amount  of 
fibrinous  exudation,  however  thick,  while  still  adherent,  can 
produce  serious  impediment  to  respiration,  this  accident  can 
only  occur  when  a  cast,  or  partial  cast,  lying  loose  in  the 
trachea  accumulates  before  the  tube  in  its  downward  course,  or 
the  membrane  being  adherent  above  and  detached  below  may 
•close  around  the  distal  extremity  of  the  tube,  and  partially  or 
completely  suspend  expiration.  I  have  had  three  deaths  from 
the  latter  cause  in  two  hundred  and  nine  cases,  occurring  from 
One  to  three  days  after  intubation.  In  two  of  these  the  pres- 
ence of  membrane  below  the  tube  was  recognized  immediately 
after  the  operation,  but  as  it  did  not  interfere  with  respiration 
at  the  time,  the  precaution  of  leaving  the  string  attached  was 
not  taken,  and  both  children  were  old  enough  to  render  this 
plan  feasible.  Pushing  down  pseudo-membrane  is  more  liable 
to  occur  in  cases  of  slow  development,  because  it  has  had  time 
to  become  detached,  and  for  the  same  reason  on  reintroducing 
the  tube  after  its  removal  for  any  cause.  When  not  held 
below  by  processes  extending  into  the  bronchi,  it  is  almost 
invariably  expelled  on  again  removing  the  tube.  In  some 
cases  I  have  succeeded  in  breaking  up  such  adhesions  by  in- 
serting a  longer  tube  or  by  inserting  and  removing  the  tube 
several  times  in  succession. 

I  have  devised  and  tried  several  instruments  for  the  re- 
moval of  pseudo-membrane  from  the  trachea,  which  have  not 
proved  satisfactory.  The  one  shown  in  the  cut  (fig.  10)  I  have 
not  3'et  used.  It  is  introduced  closed  and  expands  with  a 
spring  below  and  hugs  the  sides  of  the  trachea  while  being 
withdrawn.  It  is  of  sufficient  length  to  reach  to  the  bifurca- 
tion and  therefore  much  more  difficult  to  insert  than  a  tube. 
Even  if  completely  successful  in  accomplishing  the  object  in- 
tended, it  would  be  useless,  if  not  dangerous,  in  the  hands  of 
any  but  an  expert.  Other  means  of  minimizing  the  danger  of 
sudden  occlusion  of  the  tube  by  loose  membrane  in  the  lower 


FORMS   OF   STENOSIS   OF   THE    LARYNX. 


283 


portion  of  the  trachea  are  available  and  within  the  reach  of 
all.  The  most  important  of  these  for  older  children  who  are 
under  control  has  already  been  referred  to.  It  consists  in 
leaving-  the  string*  attached  and  fastening  it  behind  the  ear  in 
cases  in  which  the  existence  of  pseudo-membrane  below  the 
tube  is  demonstrated,  immediately  after  the  operation,  by  a 
hoarse  or  croupy  quality  of  the  cough  or  a  flapping  sound  with 
respiration  or  coughing. 

In  only  one  out  of  several  cases  in  which  I  resorted  to  this 
plan  during  the  past  year  was  it  necessary  for  the  attendant 
to  remove  the  tube.     The  patient  was  seven  years  old,  and 


Fig.  10. 


made  no  complaint  of  suffering  or  annoyance  from  the  string. 
A  cast  of  the  trachea  had  been  expelled  several  days  before 
the  operation  was  necessary,  and  another  had  formed,  its 
presence  being  manifested  not  only  by  the  symptoms  given 
above,  but  also  by  the  occasional  complete  arrest  of  the  escape 
of  air  during  violent  expiratory  efforts,  such  as  coughing. 
During  quiet  breathing,  neither  respiratory  act  was  inter- 
fered with.  The  patient  was  warned  against  touching  the 
thread  or  cutting  it  with  the  teeth.  The  father  who  acted  as 
nurse  was  directed  to  watch  her  closely,  and  in  case  of  sudden 
choking  to  pull  out  the  tube.  During  a  fit  of  coughing  in  the 
night,  sudden  dyspnosa  developed,  the  father  did  as  directed, 


284:  INTUBATION   IN    CROUP   AND    OTHER 

and  a  cast  of  the  trachea  was  expelled.  The  next  day  the 
tube  had  to  be  reinserted  for  a  short  time,  but  the  patient  re- 
covered, having  retained  the  tube  in  the  larynx  in  all  only 
fourteen  hours. 

It  is  difficult  to  leave  the  string-  attached  in  young  children, 
for  if  they  do  not  succeed  in  seizing  it  with  the  hands  they  will 
soon  chew  it  apart.  The  latter  difficulty  may  be  overcome 
when  there  is  room  to  pass  the  thread  between  two  of  the  double 
teeth.  When  this  plan  cannot  be  adopted,  a  smaller  tube  than 
the  one  suitable  for  the  age  should  be  used,  which  seldom  fails 
to  be  rejected  if  obstructed.  In  a  child  between  one  and  two 
years  of  age,  for  example,  the  No.  2  tube  should  be  removed 
and  the  smallest  one  substituted;  at  six  and  a  half  or  seven 
years  the  5-7  size  should  be  replaced  by  the  3-4.  In  the  prac- 
tice of  this  method,  the  worst  that  can  happen  is  the  rejection 
of  the  tube  when  it  is  not  necessary.  Should  this  occur  too 
frequently,  a  larger  size  would  have  to  be  used.  In  some  few 
cases  even  the  proper  size  for  the  age  as  indicated  by  the  scale 
is  coughed  out  so  often  that  a  larger  one  must  be  inserted. 

Either  of  these  plans  should  be  resorted  to  in  case  the 
symptoms  of  loose  membrane  in  the  lower  part  of  the  wind- 
pipe, absent  at  the  time  of  operation,  subsequently  show  them- 
selves. 

In  the  event  of  sudden  asphyxia,  the  nurse  should  be  in- 
structed to  quickly  grasp  the  child  and  hold  it  head  down- 
wards, at  the  same  time  shaking  it  vigorously,  the  weight  of 
the  tube  being  sometimes  sufficient  to  displace  it. 

The  obstruction  in  the  great  majority  of  these  cases  is  to 
expiration  only,  inspiration  being  free.  Air  in  excessive  quan- 
tity therefore  rapidly  accumulates  in  the  lungs,  and  this  may 
be  used  as  the  expelling  power  by  causing  some  of  it  to  escape 
suddenly,  in  imitation  of  the  act  of  coughing,  by  a  forcible 
blow  or  slap  with  the  open  hand  on  the  front  of  the  chest,  at 
the  same  time  preventing  the  descent  of  the  diaphragm  by 
pressure  of  the  other  hand  on  the  abdomen.     It  will  be  more 


FORMS    OF    STENOSIS    OF    THE    LARYNX.  285 

likely  to  succeed  if  the  patient  be  placed  across  the  knees  or 
other  hard  surface  than  if  practiced  on  the  bed. 

If  complete  occlusion  exists  death  probably  results  in  less 
than  one  minute,  and  whatever  is  done  must  be  done  quickly, 
and  by  the  nurse,  as  there  is  no  time  to  summon  the  physician. 

During-  the  fit  of  coughing"  that  immediately  succeeds  intu- 
bation, pieces  of  pseudo-membrane  are  frequently  expelled. 
These  are  usually  only  fragments  detached  from,  the  chink  of 
the  glottis  or  anterior  wall  of  the  trachea  and  carried  down 
with  the  tube,  but  they  sometimes  amount  to  considerable 
masses;  even  a  cylindrical  cast  almost  an  inch  long  I  have 
known  to  be  forced  through  the  small  opening  in  one  of  the 
medium-sized  tubes. 

I  have  never  known  any  serious  obstruction  to  result  from 
loose  membrane  above  the  tube,  but  extreme  tumefaction  of 
the  epiglottis  and  ary-epiglottic  folds  does  in  rare  cases  give 
rise  to  dangerous  constriction  at  this  point. 

In  one  case  I  recognized  this  condition  from  the  noisy  ob- 
structed inspiration,  and  easily  detected  the  overlapping  tissues 
by  inserting  the  finger.  This  difficulty  can  be  overcome  by 
coating  the  head  of  the  tube  with  several  layers  of  collodion, 
which,  if  allowed  sufficient  time  to  dry,  will  adhere  for  a  con- 
siderable length  of  time,  or  a  larger  tube  can  be  used. 

Gradual  accumulation  of  tenacious  mucus  sometimes  mixed 
with  milk-curd  occasionally  takes  place  in  the  tube  and  renders 
its  removal  for  the  purpose  of  cleaning  necessary.  It  is  more 
liable  to  occur  in  those  cases  that  cough  but  little,  also  in  very 
young  children  or  where  there  is  marked  prostration,  because 
the  expulsive  power  of  the  cough  under  these  circumstances  is 
slight.  For  the  same  reason,  when  the  lumen  of  the  tube  has 
been  seriously  encroached  upon  in  this  manner  it  is  seldom 
expelled,  as  the  volume  of  air  admitted  at  any  one  time  is 
comparatively  small. 

Coughing  out  the  tube  when  it  is  free  from  obstruction  and 
before  the  stenosis  has  been  permanently  relieved  does  not 


286  INTUBATION  IN  CROUP  AND  OTHEE 

often  occur  when  the  proper  size  has  been  used,  and  is  seldom 
attended  with  any  danger,  as  the  dyspnoea  does  not  return  im- 
mediately, except  in  those  rare  cases  in  which  there  is  exten- 
sive oedema  of  the  glottis  or  complete  paralysis  of  the  abductor 
muscles  of  the  cords.  In  either  of  these  conditions,  when 
recognized,  a  larger  tube  than  that  suitable  for  the  age  should 
be  used ;  or,  what  is  still  better,  a  tube  specially  constructed  for 
the  case,  with  extra  large  retaining-swell.  This  is  particularly 
important  in  paralysis,  which  is  likely  to  persist  for  a  consid- 
erable length  of  time,  because  the  retaining  power  which  re- 
sides principally  in  the  vocal  cords  must  be  transferred  to  the 
subglottic  division  of  the  larynx. 

The  tube  is  more  liable  to  be  expelled  in  the  act  of  vomit- 
ing than  by  coughing,  as  the  vocal  cords  in  the  latter  are  con- 
tracted, while  in  the  former  the  weight  of  the  tube  sometimes 
favors  its  rejection  from  the  position  the  patient,  if  permitted, 
is  apt  to  assume,  with  the  head  on  a  level  with  or  lower  than 
the  body. 

Owing  to  the  difference  in  the  size  of  the  larynx  in  different 
children  of  the  same  age,  it  is  impossible  to  adjust  the  tubes 
so  that  they  will  be  retained  under  all  circumstances  while 
clear,  and  at  the  same  time  permit  of  their  rejection  when 
suddenly  occluded. 

The  most  serious  injury  may  be  done  to  the  larynx  in  at- 
tempting to  remove  the  tube  if  the  extractor  be  passed  down 
beside  instead  of  into  the  opening,  and  it  is  often  impossible 
even  for  the  expert  to  locate  the  point  of  the  instrument  with 
certainty  before  separating  the  blades.  It  is  important  there- 
fore to  remember  that  no  force  whatever  is  required  to  remove 
the  tube,  and  that  any  resistance  to  the  withdrawal  of  the  ex- 
tractor proves  that  it  is  caught  in  the  tissues  on  the  outside. 
By  forcibly  removing  the  instrument  under  these  circumstances 
I  have  known  sufficient  laceration  to  be  produced  to  allow  the 
tube  to  drop  in  the  trachea,  and  this  is  the  only  way  in  which 
this  accident  can  occur  with  the  large-headed  tubes  now  in  use. 


FORMS   OF   STENOSIS    OF   THE   LARYNX.  287 

To  minimize  this  danger  as  far  as  possible  a  regulating 
screw  has  heen  added  to  the  extractor,  which  prevents  the 
blades  from  opening  any  wider  than  is  required  to  hold  the 
tube  with  sufficient  firmness  to  prevent  slipping,  and  can  be 
adjusted  to  suit  the  different  sizes.  Most  of  the  old  instru- 
ments are  too  slight,  and  therefore  too  elastic,  to  render  the 
addition  of  this  screw  of  any  service. 

Attention  to  the  following  points  will  enable  every  one  to 
detect  the  most  serious  defects  found  in  many  of  the  tubes 
still  in  the  market. 

The  head  or  shoulder  which  rests  in  the  vestibule  of  the 
larynx,  and  which  is  firmly  grasped  by  the  surrounding  tis- 
sues during  every  act  of  swallowing,  should  be  absolutely  free 
from  any  roughness  or  sharp  edges  that  would  cut  into  or 
irritate  the  intensely  inflamed  mucous  membrane.  This  por- 
tion of  the  tube — about  one-fourth  of  an  inch — has  a  slight 
backward  curve  which,  if  not  apparent,  can  readily  be  detected 
by  placing  the  anterior  edge  in  contact  with  any  level  surface. 
Its  object  is  to  give  greater  freedom  to  the  epiglottis  in  pre- 
venting the  entrance  of  food  during  the  act  of  swallowing, 
and  to  avoid  ulceration,  which  was  not  an  uncommon  occur- 
rence with  the  straight  tubes  first  used.  For  the  same  reason 
there  is  no  flange  anteriorly,  and  the  metal  here  is  left  thick 
enough  to  prevent  the  formation  of  a  cutting  edge,  as  the  epi- 
glottis is  pressed  with  considerable  force  on  this  part  with  each 
deglutition.  Those  not  familiar  with  the  object  of  this  con- 
sider it  a  serious  defect  because  occupying  room  that  should  be 
devoted  to  the  calibre.  The  metal  on  the  anterior  surface  of 
the  lower  extremity  should  be  even  thicker  than  above,  and 
smoothly  rounded  off  so  that  it  will  glide  up  and  down  over 
the  mucous  membrane  without  cutting  it. 

The  upper  extremity  of  the  tube  being  fixed,  is  raised  with 
the  larynx  and  at  the  same  time  pressed  backwards  by  the 
base  of  the  tongue,  which  pushes  the  epiglottis  before  it.  This 
lever  action  brings  the  distal  extremity  in  contact  with  the 


288  INTUBATION   IN   CROUP   AND    OTHER 

anterior  wall  of  the  trachea,  and  instead  of  occupying  a  fixed 
position,  as  it  does  above,  moves  about  half  an  inch  in  a  verti- 
cal direction.  The  upward  movement,  coincident  with  closure 
of  the  epiglottis  while  swallowing-,  is  harmless,  but  the  injury 
is  inflicted  as  the  tube,  still  in  contact  with  the  mucous 
membrane,  returns  to  what  may  be  called  its  respiratory  posi- 
tion. 

If  long  worn,  even  the  most  perfect  tube  will  produce  some 
abrasion  of  the  inflamed  and  infiltrated  tissues  at  the  point 
indicated,  from  the  frequent  rubbing,  which  occurs  with  every 
act  of  swallowing,  either  of  saliva  or  of  food,  and  probably 
amounting  to  over  a  hundred  times  daily.  If  the  tube  be 
rough  or  have  a  sharp  edge  at  this  point,  it  will  inflict  serious 
injury  on  the  mucous  membrane  even  to  laying  bare  the  carti- 
laginous rings. 

The  ulceration  thus  produced  is  sometimes  the  cause  of 
dysphagia,  and  is  in  all  probability  the  source  of  the  blood 
that  occasionally  tinges  the  expectoration  several  days  after 
intubation. 

The  retaining-swell  protects  the  sides  of  the  trachea,  and 
therefore  the  metal  on  the  lateral  aspects  of  the  distal  end 
should  be  thin  in  order  to  leave  the  entering  portion  of  the 
tube  small  to  facilitate  its  introduction. 

As  the  tube  seldom  impinges  on  the  posterior  wail  the 
metal  at  this  point  need  not  be  so  thick  as  in  front,  but  suffi- 
ciently so  to  make  it  blunt  and  smooth. 

Another  very  serious  defect,  and  a  very  common  one,  is  the 
imperfect  fitting  of  the  obturator  in  the  tube  both  above  and 
below.  If  this  exist  below,  it  fails  to  make  a  perfect  probe- 
point  and  is  liable  to  injure  the  tissues  of  the  larynx  or  scrape 
off  pseudo-membrane  in  its  downward  course.  If  above,  it 
allows  the  tube  to  wobble  when  attached  to  the  introducer, 
and  if  the  operator  fail  to  place  it  in  the  larynx  on  the  first 
attempt  the  tube  is  certain  to  slip  off,  and  besides  the  annoy- 
ance, he  is  obliged  to  lose  valuable  time  in  readjusting  it.    This 


FORMS   OF   STENOSIS   OF   THE    LARYNX.  289 

is  even  liable  to  happen  in  striking  the  base  of  the  tongue  or 
other  part  before  the  larynx  is  reached.  If  properly  made.the 
tube  and  introducing  instrument,  when  united  and  ready  for 
use,  should  be  as  free  from  motion  as  if  constructed  of  one 
piece,  and  this,  owing  to  the  joint  in  the  shank  of  the  obturator 
and  the  curve  in  the  upper  part  of  the  bore  of  the  tube,  is  diffi- 
cult to  obtain. 

I  have  also  noticed  that  the  lines  indicating  the  years  on 
the  scale  do  not  always  correspond  to  the  length  of  the  tubes, 
rendering  it  difficult  for  the  beginner  to  select  the  proper  size. 
By  observing  the  following  rule  the  scale  can  be  dispensed 
with.  The  smallest  tube  is  suitable  for  the  first  year  of  life, 
the  second  for  the  second  year,  the  third  from  two  to  four 
years,  and  the  others  for  two  years  each. 

No  instrument -maker  has  yet  succeeded  in  constructing 
these  tubes  properly  without  repeated  instructions  and  many 
failures.  It  is  therefore  not  surprising  that  those  who  never 
received  any  instruction  whatever  should  turn  out  such  grossly 
imperfect  instruments  as  are  constantly  to  be  found  in  the 
market. 

Diagnosis  of  Croup. — Croup,  from  its  characteristic  symp- 
toms, should  be  one  of  the  easiest  of  all  diseases  to  diagnos- 
ticate, and  as  a  rule  it  is,  but  in  cases  seen  for  the  first  time, 
when  moribund  or  nearly  so,  the  cough  having  ceased  and 
nothing  remaining  but  the  labored  breathing,  it  is  sometimes 
impossible  with  the  imperfect  history  obtainable  from  the  ex- 
cited parents  or  friends  to  differentiate  dyspnoea  due  to  this 
disease  from  that  produced  by  other  causes.  While  doubt 
under  such  circumstances  is  justifiable,  I  know  from  personal 
experience  that  mistakes  for  which  there  is  no  excuse  are  oc- 
casionally made  and  that  would  never  occur,  were  a  little 
attention  paid  to  the  prominent  symptoms  of  croup. 

These  symptoms  in  the  order  of  their  importance  are  the 
following:  The  peculiar  character  of  the  cough,  of  the  breath- 
ing, the  hoarseness  or  aphonia  and  dyspncea.  The  croupy 
19 


290  INTUBATION    IN    CROUP    AND    OTHER 

cough  may  be  called  a  constant  and  characteristic  symptom, 
for  the  cases  in  which  it  is  absent  with  pseudo-membrane  in 
the  larynx  can  safely  be  excluded  on  their  rarity. 

The  croupy  or  noisy  breathing-  is  almost  always  present, 
but  not  marked  in  the  early  stage  of  the  disease. 

Hoarseness  is  a  very  early  symptom,  and  occasionally  pre- 
cedes the  croupy  cough  by  a  considerable  length  of  time.  It 
is  almost  always  followed  by  aphonia  or  complete  loss  of  voice, 
except  with  violent  effort,  when  it  is  usually  possible  to  pro- 
duce a  distinct  sound.  Aphonia  in  children  should  always  be 
regarded  with  grave  suspicion,  as  in  rare  cases  it  is  the  only 
evidence  of  laryngeal  diphtheria;  while,  on  the  other  hand,  a 
fatal  stenosis  may  exist  in  the  narrow  portion  of  the  larynx 
just  below  the  vocal  cords  without  material  alteration  of  the 
voice.  It  is  particularly  liable  to  occur  in  the  ascending  cases, 
in  which  the  disease  begins  in  the  trachea  and  sometimes  pro- 
duces sufficient  infiltration  and  thickening  of  the  mucous 
membrane  of  the  subglottic  region  to  cause  apncea  before  any 
fibrinous  exudation  whatever  has  been  thrown  out.  The  cut 
(fig.  6)  represents  a  specimen  from  a  case  of  this  kind.  The 
voice,  with  the  exception  of  weakness  toward  the  end,  was 
not  altered  and  no  pseudo-membrane  existed  at  the  seat  of 
greatest  constriction. 

Dyspnoea,  except  that  due  to  spasm  which  may  occur  at 
any  stage  of  the  diesase,  is  a  late  symptom,  and  is  at  first 
mainly  inspiratory,  but  later,  when  the  respiration  assumes  a 
sawing  character,  both  respiratory  acts  are  about  equally  ob- 
structed, and  occasionally  the  exit  of  air  is  more  impeded  than 
its  entrance.  In  the  latter  case  acute  general  emphysema  is 
the  result,  with  modification  of  some  of  the  ordinary  physical 
signs  previously  described. 

It  may  be  put  down  as  a  general  rule  that  any  impediment 
to  respiration  situated  in  the  larynx  or  trachea,  or  produced 
by  pressure  on  these  parts  from  the  outside,  gives  rise  to 
greater  obstruction  to  inspiration  than  to  expiration.     The  re- 


FORMS    OF    STENOSIS    OF    THE    LARYNX.  291 

verse  is  also  true  in  several  of  the  respiratory  diseases  located 
below  these  points,  such  as  spasmodic  asthma,  emphysema, 
capillary  bronchitis,  and  the  pressure  of  enlarged  bronchial 
giands  on  or  in  the  immediate  vicinity  of  the  bifurcation.  In 
two  cases  of  the  latter  which  I  have  observed  and  verified,  the 
dyspnoea  was  markedly  expiratory  or  asthmatic,  and  while  it 
is  not  probable  that  this  always  obtains,  it  is  worth  remember- 
ing- as  an  aid  to  diagnosis  in  obscure  cases. 

The  following  diseases  are  those  most  commonly  mistaken 
for  croup,  according  to  my  own  experience :  Naso-pharyngeal 
obstruction  from  intense  tumefaction  of  the  tonsils  and  other 
tissues  at  the  entrance  of  the  fauces,  with  co-existing  occlusion 
of  the  nares.  In  two  out  of  several  such  cases  seen  during 
the  past  year,  all  malignant  forms  of  diphtheria,  there  was 
marked  cyanosis,  which  disappeared  as  the  swelling  subsided 
under  the  influence  of  warm,  mildly  astringent  irrigations;  but 
all  eventually  proved  fatal  from  the  severity  of  the  disease. 
The  noisy  breathing  simulates  that  of  croup,  but  the  cough 
and  voice  are  unaffected. 

I  have  seen  some  cases  in  which  croup  complicated  this 
condition  where  it  was  difficult  to  determine  as  to  how  much 
of  the  dyspnoea  was  laryngeal  and  how  much  pharyngeal. 
Temporarily  conveying  the  air  beyond  the  pillars  of  the  fauces 
by  the  insertion  of  a  large  catheter  or  other  means  would 
under  these  circumstances  be  decisive. 

It  should  be  remembered  also  that  with  such  a  degree  of 
malignancy,  the  intense  inflammatory  oedema  of  the  surround- 
ing tissues  may  dip  into  the  vestibule  of  the  larynx  and 
produce  fatal  stenosis  without  implicating  the  cords  and  be- 
fore pseudo-membrane  has  had  time  to  form.  The  introduc- 
tion of  an  educated  finger  is  the  best  aid  to  diagnosis  in  this 
case. 

To  be  able  to  locate  the  seat  of  the  impediment  to  respira- 
tion when  called  upon  to  intubate,  and  to  decide  whether  the 
operation,  which  cannot  remove  obstruction  in  the  phar3*nx, 


292  INTUBATION   IN   CROUP   AND    OTHER 

be  indicated  or  not,  is  the  only  advantage  to  be  derived  from 
exact  diagnosis  in  this  class  of  cases,  as  tbey  always  prove 
fatal  as  far  as  I  have  seen. 

Retro-pharyngeal  abscess  is  more  liable  to  be  confounded 
with  oedema  of  the  glottis  than  with  croup,  for  the  reason  that 
in  both  inspiration  only  is  obstructed,  but  deglutition  is  also 
interfered  with  in  the  former. 

Abscess  in  this  location  is  likely  to  be  overlooked  simply 
because  being  comparatively  rare  it  is  not  thought  of.  The 
attention  once  having  been  called  to  it,  the  diagnosis  is  easily 
made  either  by  sight  or  by  the  sense  of  touch.  The  finger 
comes  in  contact  with  a  soft  doughy  swelling  instead  of  the 
hard  posterior  wall  of  the  pharynx.  All  the  cases  of  retro- 
pharyngeal abscess  seen  by  the  author  were  in  children  under 
two  years  of  age,  and  some  of  them  were  infants  only  a  few 
months  old. 

Primary  idiopathic  oedema  of  the  glottis  is  one  of  the 
rarest  of  diseases  in  children,  and  if  mistaken  for  croup  is  of 
no  importance  as  far  as  intubation  is  concerned. 

Paralysis  of  the  abductor  muscles  of  the  glottis  only  ob- 
structs inspiration,  and  the  more  forcible  this  act  the  more 
closely  the  cords  are  approximated.  It  is  almost  exclusively 
a  sequel  of  diphtheria,  and  in  young  children  produces  asphyxia 
in  a  very  short  time. 

Larjmgismus  stridulus,  or  spasm  of  the  glottis,  is  charac- 
terized by  its  sudden  onset,  crowing  inspiration,  and  croupy 
cough.  It  is  only  the  local  manifestation  of  a  general  de- 
rangement of  the  nervous  system,  and  often  ends  in  convul- 
sions. Intubation  is  sometimes  indicated,  but  the  paroxysm 
usually  subsides  or  proves  fatal  before  there  is  time  to  sum-' 
mon  medical  aid.  Laryngeal  polypi  are  of  slow  development, 
and  affect  the  voice  for  a  considerable  length  of  time  before 
the  breathing. 

In  cases  with  obscure  history  and  unusual  symptoms  it  is 
well  to  remember  that  various  kinds  of  foreign  bodies  may 


FORMS   OF   STEXOSIS   OF   THE    LARYNX.  293 

gain  admission  to  the  larynx  and  be  retained  for  some  time 
without  producing1  complete  asphyxia. 

There  is  no  possible  excuse  for  any  error  in  diagnosis  be- 
tween pulmonary  or  bronchial  affections  and  croup  which  I 
have  known  to  be  made. 

To  differentiate  simple  catarrhal  croup  and  fibrinous  laryn- 
gitis is  a  matter  of  little  importance  as  regards  intubation, 
because  the  former  rarely  endangers  life  or  calls  for  surgical 
interference,  while  only  a  small  percentage  of  the  latter  re- 
cover without  it.  False  croup  usually  makes  its  appearance 
suddenly  in  the  night,  followed  by  marked  improvement  or 
complete  intermission  during  the  day.  Fibrinous  croup,  on 
the  contrary,  except  in  fulminant  cases,  is  rather  slow  and  in- 
sidious in  its  development,  but  steadily  progressive,  presenting 
at  first  only  slight  hoarseness  with  croupy  cough,  and  attended 
with  little  constitutional  disturbances,  when  neither  nose  nor 
pharynx  is  involved.  A  sharp  rise  of  temperature,  such  as 
104°,  points  rather  to  false  than  true  croup.  Albuminuria  is 
diagnostic  of  the  latter. 

Medical  advice  is  usually  sought  more  promptly  in  the 
false  variety,  because  it  presents  more  alarming  symptoms  at 
the  outset,  than  in  the  fibrinous  form,  which  is  often  regarded 
with  indifference  until  the  breathing  has  become  affected. 

The  much-vexed  question  of  the  identity  or  non-identity  of 
croup  and  diphtheria  would  not  be  a  subject  of  much  practical 
importance,  were  it  not  for  the  fact  that  many  lives  are  sacri- 
ficed every  year  on  account  of  the  duality  theory.  When  a 
case  is  once  diagnosticated  as  membranous  croup,  no  precau- 
tions are  taken  to  protect  other  members  of  the  family, 
because  it  is  not  a  contagious  disease. 

I  can  safely  say  that  at  least  one-fourth  of  all  the  cases 
that  I  have  been  called  upon  to  intubate  were  regarded  as 
simple  fibrinous  laryngitis  by  the  attending  physicians.  In 
many  instances  other  children  in  these  families  subsequently 
developed  diphtheria  with  fatal  results  in  not  a  few. 


294:  INTUBATION   IN   CROUP   AND   OTHER 

When  we  consider  the  frequency  with  which  diphtheria 
begins  in  the  air-passages,  and  the  number  of  physicians — 
which  I  know  from  personal  experience  to  be  in  the  majority 
— who  still  believe  in  the  distinction  between  membranous  and 
diphtheritic  croup,  the  extent  of  the  danger  of  unrestricted 
intercourse  between  the  sick  and  the  well  can  be  readily 
appreciated. 

While  there  may  be,  and  probably  is,  such  a  disease  as  acute 
non-specific  membranous  croup  in  children,  there  is  not  a  single 
sign  or  symptom  by  which  it  can  be  distinguished  from  diph- 
theria beginning  in  the  glottis.  The  only  plan,  therefore,  com- 
patible with  safety,  is  to  isolate  every  case  in  which  there  is 
even  a  suspicion  that  pseudo-membrane  may  be  developing  in 
the  larynx,  and  then  contradictory  opinions  may  be  entertained 
without  injury  to  any  one. 

The  principal  arguments  advanced  in  favor  of  the  duality 
of  croup  and  diphtheria  are  that  in  the  former  the  disease  is 
confined  to  the  air  passages,  and  is  not  attended  with  the 
usual  symptoms  of  the  latter,  viz. :  asthenia,  systemic  infec- 
tion, glandular  enlargements,  albuminuria  and  paralyses. 

Those,  on  the  contrary,  who  maintain  the  identity  of  these 
diseases  regard  the  location  or  starting-point  of  the  exudation 
as  of  no  importance,  and  attribute  the  greater  exemption  from 
general  infection  and  the  absence  of  glandular  enlargements 
to  the  smaller  surface  involved  and  the  limited  communica- 
tion of  the  absorbent  vessels  of  the  mucous  membrane  of  the 
larynx  and  trachea  with  the  glands  of  the  neck. 

My  own  experience  has  led  me  to  the  conclusion  that  if  we 
have  a  simple  fibrinous  croup  in  New  York  City  or  vicinity,  it 
must  be  extremety  rare.  A  very  small  percentage  of  the  cases 
I  have  seen  might  have  been  of  this  nature,  for  any  evidence 
to  the  contrary.  Most  of  those  so  diagnosticated  by  the  at- 
tending phj^sicians  were  subsequently  demonstrated  to  have 
been  diphtheritic  in  the  manner  previously  pointed  out  or  by 
the  presence  of  a  large  amount  of  albumin  in  the  urine,  as 


FORMS    OF    STENOSIS    OF    THE    LARYNX.  295 

there  is  no  reason  for  the  latter  complication  in  simple  mem- 
branous laryngitis. 

During-  fifteen  years'  service  at  the  New  York  Foundling- 
Asylum;,  I  have  observed  that  when  that  institution  was  free 
from  diphtheria  it  was  also  free  from  croup,  and  that  the 
prevalence  of  the  latter  always  bore  a  direct  proportion  to 
that  of  the  former.  The  same  rule  has  also  applied  to  private 
practice. 

While  we  have  no  positive  evidence,  either  clinical  or  patho- 
logical, that  there  are  two  forms  of  acute  membranous  laryn- 
gitis in  children,  yet  there  are  some  facts  which  demonstrate 
that  diphtheria  has  not  the  exclusive  right  to  produce  this 
kind  of  exudation.  Such,  for  example,  is  the  false  membrane 
that  sometimes  forms  on  blistered,  burned  or  other  wounded 
surfaces,  and  which  has  the  same  gross  and  microscopical 
appearances  as  that  of  diphtheria.  Also  that  which  occurs  in 
the  bronchi  in  chronic  fibrinous  bronchitis,  which  may  last  for 
months  and  even  years,  the  duration  alone  being  sufficient  to 
exclude  any  possible  connection  with  diphtheria,  unless  we 
admit  the  existence  of  a  chronic  form  of  this  disease. 

The  following  case  is  of  particular  interest  in  this  connec- 
tion. A  few  months  ago,  I  was  requested  by  a  physician  of 
this  city  to  visit  a  relative  of  his  who  resided  in  one  of  the 
neighboring  States,  with  a  view  to  practicing  intubation  for 
the  purpose  of  getting  rid  of  a  tracheal  cannula  that  had  been 
retained  for  some  time.  The  patient  was  a  man  about  thirty 
years  of  age,  in  excellent  health,  with  the  exception  of  the 
laryngeal  stenosis.  Five  months  before  I  saw  him  he  had  a 
severe  attack  of  acute  laryngitis,  following  exposure  to  cold, 
which  in  the  course  of  two  or  three  days  necessitated  the  per- 
formance of  tracheotomy  to  avert  threatened  asphyxia.  The 
attending  physician,  in  relating  the  history  of  the  case,  fre- 
quently referred  to  what  he  called  sloughs,  that  had  been 
ejected  daily  from  the  beginning  of  the  attack,  and  were  sup- 
posed to  have  come  from  the  larynx.     I  requested  the  patient, 


296  INTUBATION   IN   CROUP   AND    OTHER 

if  possible,  to  produce  one  of  the  so-called  sloughs  in  my  pres- 
ence, which  he  did  after  a  good  deal  of  effort.  I  found  it  to  be 
a  piece  of  pseudo-membrane,  almost  square,  and  about  half  an 
inch  in  diameter,  somewhat  thinner  than  that  ordinarily  found 
in  croup. 

I  submitted  one  of  these  specimens  to  Dr.  W.  P.  Northrup, 
pathologist  to  the  New  York  Foundling  Asylum,  for  micro- 
scopical examination,  who  pronounced  it  identical  in  every 
particular  with  the  fibrinous  exudation  of  diphtheria. 

In  the  mirror  the  deposit  could  be  seen  about  equally  dis- 
tributed over  both  vocal  cords  and  nowhere  else. 

When  questioned  on  the  subject,  the  patient  denied  syphilis, 
because  fully  convinced  that  he  never  had  it ;  but  he  had  a  node 
on  the  shin  at  the  time,  which  had  been  painful  at  night,  and 
this,  together  with  the  laryngitis,  was  the  only  manifestation 
of  the  disease  that  had  ever  existed. 

Under  the  influence  of  mercury  and  the  iodide,  the  pseudo- 
membrane  disappeared  in  four  days,  and  never  returned. 

Making  all  due  allowance  for  the  fact  that  the  inflamma- 
tory trouble  in  the  larynx  was  syphilitic,  the  rapid  cure  of  the 
fibrinous  element,  which  had  persisted  for  five  months  unin- 
fluenced by  a  variety  of  local  applications,  argues  forcibly  in 
favor  of  the  mercurial  treatment  of  croup. 

This  patient  was  in  daily  contact  with  children  during  the 
whole  course  of  his  disease,  none  of  whom  suffered  from  any 
affection  of  the  throat. 

Prognosis. — Diphtheritic  or  fibrinous  croup  without  the 
aid  of  intubation  or  tracheotomy  proves  fatal  in  from  90  to  95 
per  cent,  of  the  cases. 

About  10  per  cent,  of  those  that  I  have  been  called  to  in- 
tubate finally  struggled  through  without  it,  and  in  private 
practice,  27  per  cent,  with  intubation.  This  makes  a  total  of 
37  per  cent.,  which  may  be  taken  as  the  best  results  that  can 
be  obtained  in  a  large  number  of  cases  extending  over  a  suffi- 


FOliMS    OF    STENOSIS    OF    THE    LAKVXX.  297 

cient  period  of  time  to  include  all  types  of  the  disease,  mild 
and  severe. 

Those  who  practice  either  operation  early,  of  course,  include 
the  cases  that  would  otherwise  recover  if  not  interfered  with, 
but  this  does  not  materially  alter  the  average  just  given. 

The  latest  intubation  statistics  are  those  compiled  by  Dr. 
Dillon  Brown,  who  in  the  month  of  November,  1888,  collected 
2372  cases  from  159  operators,  with  646  recoveries,  or  27.2  per 
cent. 

The  age  of  the  patient,  the  character  of  the  epidemic,  the 
origin,  nature,  and  extent  of  the  exudation  and  the  complica- 
tions, are  the  important  factors  to  be  considered  in  estimating 
the  probable  termination  in  any  given  case.  Of  these,  age  is 
by  all  odds  the  most  important. 

Although  several  recoveries  following  intubation  for  croup 
in  children  under  one  year  of  age  have  already  been  reported, 
the  percentage  is  very  small.  During  the  second  year  of  life, 
there  is  a  marked  improvement  in  the  results,  and  so  on  with 
increasing  age,  until  the  period  of  puberty  is  approached, 
when  the  statistics  so  far  indicate  a  falling  off  in  the  percent- 
age of  recoveries.  This  may  be  explained  by  the  fact  that  the 
liability  to  croup  decreases  with  age,  and  that  the  number  of 
older  children  so  far  intubated  is  too  limited  to  warrant  any 
conclusion  on  this  subject.  Furthermore,  owing  to  the  larger 
size  of  the  larynx  in  these  cases,  recovery  more  frequently  re- 
sults without  operation  than  in  young  children,  and  intubation 
is  therefore  only  called  for  in  the  worst  forms  of  the  disease. 
For  the  same  reason,  when  laryngeal  diphtheria  in  the  adult 
produces  sufficient  stenosis  to  require  surgical  aid,  it  indicates 
a  malignancy  of  the  disease  that  is  seldom  recovered  from. 

Croup  that  prevails  during  fatal  epidemics  of  pharyngeal 
diphtheria  is  proportionately  fatal  and  principally  from  the 
same  causes,  viz.,  greater  frequency  of  systemic  infection,  of 
nephritis,  pneumonia,  and  also  greater  tendency  to  invade  the 
bronchial  tubes.     The  latter  is  much  more  liable  to  occur  when 


298  INTUBATION  IN  CROUP  AND  OTHER 

the  disease  begins  in  the  larynx,  than  in  those  cases  in  which 
the  exudation  has  existed  for  several  days  in  the  fauces,  thus 
having  run  part  of  its  course  before  invading*  the  air-passages. 
For  this  reason  the  prognosis  is  less  favorable  in  the  so-called 
membranous  croup  than  in  the  form  that  is  recognized  by  all 
as  diphtheritic. 

Distribution  of  the  pseudo-membrane  over  a  large  surface, 
as  when  with  the  larynx  the  nose  as  well  as  the  fauces  is  in- 
volved, thick  deposit,  dark  color  of  the  exudation,  foul  odor, 
great  tumefaction  of  the  tissues  in  the  throat  and  of  the 
glands  on  the  outside  are  unfavorable  to  recovery. 

Cases  with  scanty  secretion  of  urine  with  a  perceptible 
amount  of  blood  or  large  quantity  of  albumin,  such  as  fifty 
per  cent,  or  over,  almost  invariably  terminate  fatally.  A 
more  copious  secretion  with  the  same  amount  of  albumin  is  of 
less  serious  import.  I  have  never  known  albumin  to  be  absent 
in  severe  cases,  but  it  must  be  looked  for  daily,  as  the  urine 
may  be  free  from  it  one  day,  and  loaded  the  next.  A  high 
temperature  on  the  second  or  third  day  after  intubation  is  an 
evil  omen,  because  it  usually  indicates  extension  of  the  disease 
to  the  bronchi,  sepsis,  or  pneumonia  or  all  combined.  When 
the  laryngeal  stenosis  has  persisted  for  some  time,  and  is  suffi- 
ciently pronounced  to  call  for  surgical  interference,  the  tem- 
perature in  the  great  majority  of  cases  is  little  above  the 
normal.  This,  to  some  extent,  at  least,  is  due  to  diminished 
oxidation  in  the  tissues  from  the  limited  supply  of  air  admitted 
to  the  lungs,  and  explains  the  rapid  rise  of  temperature  that 
not  unfrequently  occurs  soon  after  intubation,  and  before 
sufficient  time  has  elapsed  for  the  development  of  any  com- 
plication. Fever  coming  on  in  this  manner  is  not  so  liable  to 
persist,  and  does  not  possess  the  same  prognostic  significance 
as  when  it  shows  itself  one  or  more  days  after  the  operation. 

Children  in  the  neighborhood  of  four  or  five  years  of  age 
breathe,  in  health,  about  twenty-five  times  per  minute.  An 
increase  in  the  number  of  respirations  to  forty  or  more  usually 


FORMS   OF   STENOSIS   OF   THE    LARYNX.  299 

indicates  either  a  narrowing-  of  the  calibre  of  the  bronchi  by 
pseudo-membrane  or  pneumonia,  the  latter  being"  a  later  de- 
velopment. 

Any  considerable  invasion  of  the  lower  air-passages  by  the 
disease,  almost  invariably  occludes  some  of  the  bronchial 
tubes,  which  is  followed  by  collapse  of  the  corresponding  por- 
tions of  the  lungs,  and  this,  together  with  the  decrease  in  the 
lumen  of  the  others,  sufficiently  explains  the  acceleration  of 
the  breathing  when  no  pneumonia  exists. 

In  young  children  it  is  not  uncommon  for  the  respirations 
under  these  circumstances  to  run  as  high  as  from  eighty  to 
one  hundred  or  more  per  minute. 

Treatment  of  Croup. — In  estimating  the  value  of  any 
remedy  in  the  treatment  of  croup,  a  disease  so  fatal  under  all 
circumstances  and  attended  by  so  many  grave  complications, 
it  is  important  to  resist  the  temptation  of  being  influenced  by 
the  result  obtained  in  a  few  cases,  whether  it  be  favorable  or 
otherwise. 

The  mortality  from  diphtheria,  and  consequently  that  from 
croup,  varies  so  much  in  different  epidemics,  that  it  is  neces- 
sary before  arriving  at  any  conclusion  not  only  to  observe  a 
large  number  of  cases,  but  also  that  these  should  extend  over 
a  sufficient  period  of  time  to  include  all  types  of  the  disease. 

As  my  own  views  on  the  medicinal  treatment  of  diphtheria 
and  croup  coincide  so  perfectly  with  those  of  the  author  of 
this  work  it  is  only  necessary  for  me  to  indorse  the  method 
advocated  by  Dr.  Billington,  to  which  the  reader  is  referred, 
and  give  some  directions  for  the  management  of  laryngeal 
diphtheria  following  intubation. 

Of  the  many  therapeutic  agents  that  have  been,  and  are 
still  employed  in  the  treatment  of  croup,  I  believe  the  bi- 
chloride of  mercury  deserves  the  first  place.  Very  few,  if  &ny, 
of  those  who  have  used  it,  after  having  had  sufficient  experi- 
ence with  other  remedies  to  render  their  opinion  of  much 
value,  have  abandoned  its  use  after  a  fair  trial. 


300  INTUBATION"   IN   CROUP   AND    OTHER 

After  intubation  the  same  treatment  is  continued,  with  the 
exception  of  an  interval  of  two  or  three  hours  following-  the 
operation,  during  which  nothing  is  given  by  the  mouth,  in 
order  to  allow  time  for  the  larynx  to  become  accustomed  to 
the  presence  of  the  foreign  body.  In  some  cases  I  have  found 
it  necessary  to  administer  small  doses  of  whisky  or  brandy 
undiluted  soon  after  placing  a  tube  in  the  larynx,  for  the  pur- 
pose of  exciting  sufficient  cough  to  expel  accumulated  secre- 
tions and  loose  membrane,  the  tube  with  string  attached  fail- 
ing to  accomplish  this. 

With  a  properly  fitting  tube  in  the  larynx,  the  difficulty  of 
swallowing  is  due  principally  to  swollen  condition  of  the  epi- 
glottis, which  is  common  in  croup.  This  is  demonstrated  by 
the  fact  that  in  other  forms  of  stenosis  in  which  the  epiglottis 
is  not  involved,  the  difficulty  of  deglutition  is  soon  overcome. 

Some  of  the  liquids  swallowed  undoubtedly  gain  admission  to 
the  trachea  through  the  tube,  but  are  promptly  expelled  by  the 
coughing  thus  excited,  and  are  therefore  harmless.  But  should 
the  sensibility  be  so  much  blunted  that  no  reflex  action  follows 
the  contact  of  extraneous  matter  with  the  lining  membrane  of 
the  air-passages,  there  is  nothing  to  prevent  the  gravitation 
of  whatever  passes  through  the  tube  to  the  smaller  bronchi 
and  alveoli.  The  impaired  sensibility  in  such  cases  is  due  to 
some  form  of  toxasmia  which  precludes  any  reasonable  chance 
of  recover}7,  and  it  is  therefore  scarcely  worth  subjecting  the 
patient  to  the  annoyance  of  feeding  by  stomach  tube.  But 
there  are  some  cases  that  suppress  the  cough  because  it  is 
painful,  and  in  these  the  plan  of  feeding  suggested  by  Dr.  Cas- 
tleberry,  of  Chicago,  may  be  tried.  It  consists  in  overcoming 
gravitation  by  placing  the  head  considerably  lower  than  the 
body,  and  drinking  through  a  glass  tube,  nursing  bottle,  etc., 
which  allows  any  fluid  that  enters  the  tube  to  escape  without 
coughing. 

Some  patients  swallow  better  by  taking  a  small  quantity 
in  the  mouth  at  a  time,  others  by  filling  the  mouth.    Infants 


FORMS   OF   STENOSIS   OF   THE    LARYNX.  301 

at  the  breast  swallow  better  than  older  children,  and  most 
cases  can  drink  better  from  a  nursing'  bottle  than  from  a  cup 
or  glass,  and  on  the  same  principle  by  sucking  through  a  tube. 
Patients  with  high  temperature,  suffering  from  great  thirst, 
will  take  a  long  drink  without  stopping  to  cough,  although 
the  desire  to  do  so  be  very  great.  This  should  not  be  per- 
mitted, as  it  gives  time  for  some  of  the  liquid  to  enter  the 
bronchi.  The  glass  should  be  removed  after  every  two  or 
three  acts  of  swallowing,  and  the  child  encouraged  to  cough. 
These  precautions  do  not  apply  to  cases  that  swallow  well, 
which  is  not  uncommon  after  the  tube  has  remained  in  the 
larynx  for  a  few  days,  if  the  functions  of  the  epiglottis  be  not 
much  impaired. 

Nourishment  in  the  solid  and  semi-solid  forms,  which  are 
swallowed  better  than  liquids,  should  be  given  the  preference 
when  children  can  be  induced  to  take  them. 

Rectal  feeding  should  be  resorted  to  in  case  a  sufficient 
amount  of  nutriment  cannot  be  given  by  the  mouth.  Warm 
milk  with  whisky,  to  which  the  albumen  of  one  or  two  eggs 
can  be  added,  is  the  most  convenient  for  this  purpose.  Pep- 
tonized milk  or  the  expressed  juice  of  meat  is  still  better. 

The  Leube  Rosenthal  solution  of  meat,  dissolved  in  warm 
water,  is  readily  absorbed  by  the  rectum  if  retained  long 
enough,  as  I  have  demonstrated  many  times. 

These  injections  should  not  be  given  oftener  than  once  in 
three  or  four  hours,  or  in  larger  quantities  than  one  or  two 
ounces  to  a  child  four  or  five  years  old,  otherwise  thej7-  are  soon 
rejected.  When  the  bowel  becomes  irritable,  tolerance  for 
small  quantities  is  sometimes  re-established  by  a  large  injec- 
tion of  warm  water;  and  should  this  fail,  a  few  drops  of  lauda- 
num in  warm  sweet-oil  or  starch  can  be  injected  with  a  small 
S3Tringe  and  allowed  to  remain  about  three  quarters  of  an 
hour  before  using  the  nutrient  enema.  In  this  manner  the 
bowel  can  be  used  many  days  in  succession,  and  aids  wonder- 
fully in  sustaining  the  vital  powers  until  the  patient  can  be 


302  INTUBATION    IN    CROUP    AND    OTHER 

induced  to  take  a  sufficient  quantity  of  nourishment  by  the 
mouth. 

Intubation  cases  are  not  the  only  ones  that  call  for  rectal 
alimentation. 

It  is  not  uncommon  for  children  suffering  from  diphtheria 
or  scarlet  fever  to  refuse  all  kinds  of  nourishment  for  several 
days  in  succession,  and  if  compelled  to  take  it  or  it  is  given  by 
the  stomach  tube,  it  is  almost  immediately  rejected.  Rectal 
feeding  is  just  as  urgently  demanded  under  these  circum- 
stances as  if  the  inability  to  take  food  were  due  to  a  tube  in 
the  larynx. 

The  most  fatal  of  all  the  complications  of  croup  is  un- 
doubtedly the  extension  of  the  disease  to  the  lower  air-passages, 
or  fibrinous  bronchitis ;  for  the  prevention  of  which  there  is  no 
remedy  known  at  present.  Mercury,  especially  the  bichloride, 
probably  exerts  some  limiting  or  controlling  power  over  the 
fibrinous  exudation,  which  would  sufficiently  explain  the  more 
favorable  results  obtained  with  this  than  with  any  other 
remedy. 

Nephritis  is  often  a  serious  complication,  but  is  usually  in 
proportion  to  the  severity  of  the  diphtheria  and  the  amount 
of  systemic  infection.  Thorough  disinfection  of  the  absorbing 
surfaces  in  the  throat  and  nose  is  therefore  an  important 
part  of  the  treatment.  The  improvement  in  the  albuminuria 
goes  hand  in  hand  with  that  of  the  original  disease,  and  rapid 
recovery  follows  as  soon  as  the  poison  is  completely  eliminated 
from  the  circulation. 

From  the  physiological  fact  that  urea  is  a  constant  con- 
stituent of  normal  sweat,  and  that  its  quantity  is  largely  in- 
creased when  there  is  a  deficient  elimination  by  the  kidneys, 
free  action  of  the  skin  is  a  rational  and  valuable  means  of 
carrying  off  excrementitious  products  that  would  otherwise 
accumulate  in  the  blood  and  tissues  when  the  function  of  the 
kidneys  is  seriously  impaired.  There  is  no  better  method  of 
accomplishing  free  diaphoresis  than  that  necessarily  produced 


FORMS    OF    STENOSIS    OF    THE    LARYNX.  606 

by  the  steam  treatment  under  a  tent.  Under  these  circum- 
stances the  temperature  of  the  air  immediately  surrounding 
the  patient  can  be  kept  as  high  as  80°  with  advantage.  With- 
out the  kidney  complication,  75°  is  sufficient. 

The  high  temperature  that  usually  accompanies  the  pneu- 
monia, fibrinous  bronchitis,  and  sepsis  can,  in  most  cases,  be 
kept  within  bounds  by  the  use  of  antipyrin  or  antifebrin  com- 
bined with  digitalis,  which,  even  if  they  accomplish  nothing  in 
the  way  of  saving  life,  contribute  a  good  deal  to  the  comfort 
of  the  patient,  by  allaying  the  thirst  and  restlessness  produced 
by  the  fever. 

A  sufficient  amount  of  sleep  should  always  be  procured,  and 
it  is  much  better  to  give  an  anodyne  for  this  purpose  than  to 
allow  a  child  to  pass  a  restless,  wakeful  night.  If  due  to  pain 
or  irritation  from  the  tube  in  the  larynx  or  excessive  cough, 
an  opiate  is  the  only  remedy  that  will  afford  relief,  otherwise 
sulphonal,  in  doses  of  from  three  to  five  grains,  or  a  mixture  of 
bromide  and  chloral,  will  answer  the  same  purpose. 

Many  times  in  answer  to  the  question  whether  the  little 
patient  had  obtained  any  sleep  during  the  night,  I  have  been 
told  by  the  mother  that  it  would  have  slept,  had  she  not  been 
obliged  to  administer  the  medicine  every  half-hour  or  hour. 

Nervous,  irritable  children  who  remain  wakeful  for  some 
time  after  having  been  roused  to  take  their  dose,  should  be 
allowed  at  least  three  hours  of  uninterrupted  sleep  every 
night.  From  the  unsatisfactory  results  obtained  with  any  of 
the  remedies  at  present  within  reach,  I  believe  it  is  much  safer 
to  temporarily  suspend  medication  than  to  seriously  interfere 
with  sleep. 

Intubation  in  the  Adult. — The  operator  who  has  acquired 
proficiency  in  performing  intubation  in  children,  will  experi- 
ence great  difficulty  when  called  upon  for  the  first  time  to 
operate  on  the  adult.  The  difference  is  due  to  the  larger  size 
of  the  larynx  in  the  latter,  but  particularly  to  its  greater  dis- 
tance from  the  mouth.     It  is  only  necessary  to  reach  far 


304  INTUBATION   IN   CROUP   AND   OTHER 

enough  behind  the  epiglottis  to  hold  it  erect,  and  this  can 
usually  be  done  by  crowding  the  finger  well  back  in  the  right 
angle  of  the  mouth.  In  one  case  I  failed  absolutely,  after  re- 
peated attempts,  to  do  more  than  touch  the  tip  of  the  epiglottis 
without  inserting  two  fingers,  which  filled  the  pharynx  and 
left  no  room  for  the  passage  of  the  tube.  Intubation  was 
finally  accomplished  in  this  patient  by  the  aid  of  the  mirror, 
which  will  probably  prove  the  better  plan  for  those  familiar 
with  laryngoscopic  manipulations.  In  the  latter  case  it  is 
necessary  to  drop  the  mirror  and  quickly  insert  the  finger  to 
push  the  tube  home  and  hold  it  down  while  the  obturator  is 
being  removed,  for  if  the  thickest  portion  of  the  retaining-swell 
be  not  carried  well  below  the  cords,  which  is  often  impossible 
while  still  attached  to  the  introducer,  the  tube  is  immediately 
rejected.  The  removal  of  the  tube  from  the  adult  larynx  can 
be  accomplished  with  greater  ease,  and  with  less  discomfort 
to  the  patient,  by  guiding  the  extractor  into  it  by  the  aid  of 
the  mirror,  than  by  the  finger,  as  is  necessary  in  children. 
Very  little  practice  with  the  laryngoscope  is  required  for  this 
purpose. 

For  any  form  of  acute  stenosis  of  the  larynx  in  the  adult, 
two  tubes  of  different  sizes,  the  smaller  for  the  female,  the 
larger  for  the  male,  I  believe  will  prove  sufficient.  But  for  the 
dilatation  of  chronic  stricture,  especially  the  cicatricial  form, 
a  set  of  about  ten  tubes  will  be  required,  and  the  larger  of 
these  can  be  used  in  acute  cases  in  the  adult  male,  the  medium 
sizes  in  the  adult  female,  and  the  smallest  during  the  years  of 
adolescence. 

A  special  introducer  and  extractor,  longer  and  much 
stronger  than  those  used  for  children,  are  necessary.1 

Intubation  has  already  been  successfully  practiced  in  almost 
all  the  different  varieties  of  stenosis  that  occur  in  the  adult 

Niemann  &  Co.,  of  this  city,  is  the  only  firm  at  present  manufact- 
uring tubes  and  accessory  instruments  suitable  for  adults. 


FOKMS    OF    STENOSIS    OF   THE   LARYNX.  805 

larynx,  viz.: — Acute  oedema  of  the  glottis,  erysipelatous  in- 
flammation, laryngeal  diphtheria,  perichondritis,  syphilitic 
and  tubercular  laryngitis,  paralysis  of  the  abductor  muscles 
of  the  cords,  and  temporarily,  in  neoplasm. 

In  cases  requiring  the  retention  of  a  tube  for  several 
months,  it  is  important  to  change  the  points  of  pressure  in  the 
vestibule  of  the  larynx  about  once  in  two  weeks,  in  order  to 
prevent  erosion  of  the  mucous  membrane,  with  consequent 
sprouting  of  fungous  granulations,  which  is  liable  to  occur 
from  the  compression  exerted  by  the  constrictor  muscles  dur- 
ing every  act  of  swallowing.  The  larger  head  that  goes  with 
the  increase  in  the  size  of  the  tubes  required  for  the  dilatation 
of  the  stricture,  accomplishes  this  purpose  until  the  maximum 
size  has  been  reached,  when  the  pressure  can  be  transferred  to 
other  points  by  changing  the  shape  of  the  shoulder  of  the  tube. 
It  can,  for  example,  be  lifted  higher  in  the  larynx  by  increasing 
the  thickness  in  the  vertical  direction,  having  the  diameter 
the  same. 

A  hard-rubber  tube  may  be  allowed  to  remain  in  the  larynx 
for  a  much  longer  time  than  one  constructed  of  metal,  because, 
owing  to  its  lightness,  it  does  not  occupy  a  fixed  position,  but 
moves  upward  by  coughing,  and  is  again  pressed  downward 
by  the  act  of  swallowing. 

Another  objection  to  the  long  retention  of  a  metallic  tube 
is  the  fact  that  the  gold-plating  soon  disappears  in  places, 
followed  by  erosion  of  the  metal  and  the  deposit  of  calcareous 
matter,  which  produces  a  good  deal  of  irritation. 

I  have  occasionally  found  some  calcareous  granules  on 
tubes  that  were  not  long  retained,  and  on  which  the  plating- 
appeared  to  have  been  intact. 

The   difficulty   of    deglutition   that   follows  intubation  in 

croup,  and  that  often  persists  as  long  as  the  tube  remains  in 

the  larynx,  is  not  a  prominent  feature  in  chronic  stenosis.     The 

epiglottis  being  usually  in  a  normal  condition,  soon  learns  to 
20 


306  INTUBATION   IN   CROUP   AND   OTHER. 

assume  the  whole  duty  of  protecting-  the  larynx,  and  accom- 
plishes this  purpose  very  perfectly,  after  a  little  time,  without 
the  aid  afforded  "by  the  constriction  of  the  latter,  which,  I  "be- 
lieve, is  the  more  important  of  the  two. 

With  a  properly  fitting-  tube,  a  healthy  epiglottis,  and  free- 
dom from  much  inflammation  or  thickening  above  the  vocal 
cords,  the  difficulty  of  swallowing  at  first  experienced  is  usu- 
ally completely  overcome  in  about  a  week. 

In  the  treatment  of  chronic  stenosis  of  the  larynx  in  chil- 
dren, the  set  of  croup  tubes  will  do  to  begin  with,  but  the  cali- 
bre of  these  is  only  sufficient  for  free  respiration  in  a  state  of 
rest,  and  therefore  not  large  enough  to  supply  the  increased 
demand  for  oxygen  produced  by  the  active  exercise  that  these 
little  patients  take,  which  is  not  materially  different  from  that 
of  ordinary  health.  In  the  beginning,  therefore,  when  it  is  only 
possible  to  pass  a  small  tube  through  the  stricture,  it  will  be 
necessary  to  restrict  the  amount  of  exercise  or  even  confine 
the  patient  to  bed  in  order  to  avoid  dyspnoea. 

Unlike  the  conditions  present  in  croup,  with  its  intense 
inflainmator\T  infiltration  of  the  mucous  membrane,  which 
often  leads  to  spontaneous  ulceration,  the  larynx  in  these 
cases,  aside  from  the  constriction,  is  usually  normal,  and  the 
same  danger  of  injury  from  pressure  does  not  exist.  Much 
larger  tubes,  and  more  nearly  cylindrical  if  required,  can  there- 
fore be  used  with  perfect  safety. 

The  length  of  time  required  for  the  dilatation  of  chronic 
stenosis  of  the  larynx  will  depend  on  the  degree  of  constric- 
tion, its  cause,  and  duration.  In  complete  occlusion,  atrophied 
muscles  and  anchylosed  joints,  the  necessary  result  of  sus- 
pended function,  render  such  cases  the  most  unfavorable  for 
speedy  cure. 

Even  a  very  small  opening  in  the  larynx,  that  allows  the 
entrance  of  some  air,  which  keeps  the  arytenoids  and  the  mus- 
cles that  move  them  in  use,  gives  a  better  prospect  of  recovery 
in  a  reasonable  time. 


FORMS   OF   STENOSIS   OF   THE    LARYNX.  807 

Cases  in  which  a  tracheal  cannula  has  been  retained  as  long- 
as  a  year  or  more  will  usually  require  dilatation  for  several 
months  to  effect  a  permanent  cure. 

Where  complete  closure  of  the  larynx  exists,  divulsion 
should  be  practiced  through  the  tracheal  wound  from  below, 
because  owing  to  the  gradual  inclination  of  the  vocal  cords 
from  the  circumference  towards  the  centre  in  this  situation, 
there  is  no  danger  of  passing  the  sound  or  other  instrument 
used  anywhere  else  than  in  the  line  of  the  original  opening; 
while  if  done  from  above,  through  the  mouth,  there  can  be  no 
certainty  that  the  point  of  the  instrument  is  not  in  one  of  the 
ventricles,  which  it  would  penetrate  with  the  employment  of 
less  force  than  would  be  required  to  pass  through  the  cicatri- 
cial tissue  uniting  the  vocal  cords. 

In  the  majority  of  the  cases  so  far  treated  by  myself  and 
others,  syphilis,  usually  in  its  tertiary  form,  was  the  cause  of 
the  stenosis. 

In  two  children,  one  a  constriction,  the  other  a  complete 
occlusion,  the  cause  was  high  tracheotomy  for  croup.  The 
operation  in  both  of  these  cases  involved  at  least  the  subglottic 
division  of  the  larynx,  which  is  often  selected  because,  being 
less  deeply  seated,  it  is  more  accessible  than  the  trachea. 

In  one  adult,  also,  who  had  worn  a  tracheal  cannula  for 
two  years,  the  opening  had  been  made  in  the  cricothyroid 
space,  and  in  another  immediately  below  the  cricoid  cartilage. 

The  lumen  of  the  trachea  is  large,  while  that  of  the  larynx 
is  comparatively  small,  and,  besides  the  delicate  articular  and 
muscular  apparatus  of  the  latter  is  liable  to  serious  injury 
from  the  irritation  of  a  cannula  if  long  retained.  There  is 
therefore  no  excuse  for  laryngotomy  or  high  tracheotomy,  ex- 
cept for  the  removal  of  a  foreign  body  or  neoplasm,  and  possi- 
bly when  pressed  for  time  in  case  of  threatened  asphyxia,  as 
these  operations  are  undoubtedly  the  most  frequent  cause  of 
retained  cannulas  in  croup  and  other  forms  of  obstruction 
that  recover  in  a  short  time. 


308  INTUBATION   IN   CROUP,    ETC. 

To  insure  success  in  management  of  chronic  stenosis  of  the 
larynx,  some  ingenuity  and  a  great  deal  of  patience  and  per- 
severance are  necessary  in  order  to  overcome  the  many  diffi- 
culties encountered.  No  set  of  instruments,  however  complete, 
will  he  sufficient  for  all  cases,  no  two  of  which  are  alike,  and 
the  construction  of  tubes  adapted  to  special  peculiarities  will 
sometimes  be  required. 


INDEX. 


Abbrcrombie,     albuminuria    in 
diphtheritic  paralysis,  115. 
lesions  found  in  diphtheritic 
paralysis,  67. 
Abscess,     retro-pharyngeal,    mis- 
taken for  croup,  292. 
Accommodation,     defective,      in 

diphtheritic  paralysis,  109. 
Acid,  boracic,  in  the  treatment  of 
diphtheria,  194. 
carbolic,  local  use  of,  180. 
citric,  local  use  of,  199. 
lactic,    as  a  solvent  of  false 

membrane,  164. 
salicylic,  formula  for  internal 
administration  of,  220. 
local  use  of,  180. 
sulphurous,  internal  use  of, 
183,  222. 
Aconite,  219. 
Adamson,    E.,     internal    use    of 

tincture  of  iodine,  186. 
Adenitis  in  diphtheria,  treatment 
of,  231. 
in  nasal  diphtheria,  74. 
in  pharyngeal  diphtheria,  71. 
prognostic  significance  of,  142. 
Adult,  intubation  in  the,  303. 
Aerotherapy,  antiseptic,  197. 
Aetius  Cletus,  epidemic  of  diph- 
theria described  by,  5. 
Aetius  of  Amida,  description  of 

diphtheria  by,  3. 
Afanasieff,  V.,  poisoning  by  chlo- 
rate of  potassium,  191. 
Age,  in  relation  to  success  of  in- 
tubation, 297. 
influencing  the  occurrence  of 
diphtheria,  16. 
Air,  communication  of  diphtheria 

through  the,  28. 
Albuminuria,  complicating  diph- 
theria, 89,  302,. 
duration  of,  92.* 
in  diphtheritic  paralysis,  115. 


Albuminuria  in  relation  to  prog- 
nosis, 91,  298. 
of  diphtheria  and  of   scarla- 
tina,   differences    between, 
92. 
therapeutic    indications   fur- 
nished by,  234. 
time  of  occurrence  of,  90. 
Alcohol  in  heart  failure,  233. 

in  laryngeal  diphtheria,  243.    , 
in  the  treatment  of  diphthe- 
ria, 204. 
Alum,  local  employment  of,  161. 
Amaurosis,  diphtheritic,  113. 
America,  early  epidemics  of  diph- 
theria in,  8. 
Angina,   diphtheroid,    in    scarla- 
tina, 104. 
maligna,  3. 

ulcero-membranous,  diagnosis 
of,  from  diphtheria.  123. 
Animals,  diphtheria  in,  23 

inoculation   experiments  on, 
26. 
Antifebrin,  219,  303. 
Antipyretics  in  the  early  stage  of 

pharyngeal  diphtheria,  218. 
•Antipyrin,  219,  303. 
Antiseptic  aerotherapy,  197. 
fumigations,  198. 
tracheotomy    in  the   preven- 
tion of  bronchial  diphthe- 
ria, 249. 
treatment,  prophylactic  value 
of,  147. 
Antiseptics  in  the  treatment  of 

diphtheria,  170. 
Anus,  diphtheria  of  the,  88. 
Appendix,  259. 
Applications,  local,  156. 
Apomorphia   in   laryngeal  diph- 
theria, 243. 
Archambault-Reverdy,  159. 
Aretceus  of  Cappadocia,  diphthe- 
ria described  by,  2. 


310 


INDEX. 


Aretseus  of  Cappadocia,   on  the 
use  of  caustics,  157. 
recommended  the  use  of  alum 
and  tannin,  161. 
Articulation,  difficult,  in  diphthe- 
ritic paralysis,  109,  111 
Artificial  feeding  after  intubation, 
301. 
in  diphtheritic  paralysis, 
256. 
respiration  in  diphtheritic  pa- 
ralysis, 256. 
Asclepiades,  2,  265. 
Asthenia  in  constitutional  poison- 
ing, 76. 
Asthenopia  in  diphtheritic  par- 
alysis, 109. 
Astringents,  local  employment  of, 

161. 
Ataxia,  diphtheritic,  110. 
Atomizers  for  use  in  the  treat- 
ment of  laryngeal  diptheria, 
238. 
for  use  in  spraying  the  phar- 
ynx, 216. 
Aubrun,   perchloride  of    iron  in 

diptheria,  202. 
Aurelianus,    Coelius,    description 

of  diphtheria  by,  3. 
Author's   conclusions   as    to   the 
etiology  of  diphtheria,  43. 
treatment  of  diphtheria,  210. 
views  as  to  the  non -identity 
of  croup  and  diphtheria,  61. 
views  as  to  the  primary  na- 
ture of  diphtheria,  96. 
Auto-inoculation    of    diphtheria, 
25. 

Babes,  bacteriological  investiga- 
tions of,  39. 
Bacillus  of  Klebs  and  Loeffler,  259. 
Bacteria,   absence  of,  in  artifici-_ 
ally  produced  pseudo-mem- ' 
brane,  59. 
aerobic  and  anerobic,  42. 
in  diphtheritic  membrane,  31, 

259,  263. 
resistance  of  the  organism  to 
invasion  by,  171. 
Baillou,   epidemic  of  diphtheria 

described  by,  4. 
Barbosa,  epidemic  of  diphtheria 

described  by,  5. 
Bard,  Samuel,  treatise  on  diph- 
theria by,  9. 
Baruch,  S.,  internal  use  of  oil  of 

turpentine,  196. 
Beale,  micro-organisms  in  diph- 
theria, 32. 
Becquerel,  14. 


Beef -tea  and  alcohol,  comparative 

effects  of,  as  stimulants,  206. 
Benzoate  of  sodium  in  the  treat- 
ment of  diphtheria,  190,  222. 
Bernhardt,   loss  of  knee-jerk  in 
convalescence  from  diphtheria, 
114. 
Billroth,  micro-organisms  in  diph- 
theria, 32. 
Birds,  diphtheria  in,  23. 
Bladder,  diphtheria  of,  88.    . 

diphtheritic  paralysis  of  the. 
113. 
Blair,      Patrick,      epidemic      of 

"  croops  "  described  by,  6. 
Bloebaum,  employment  of  galva- 
» no-cautery  by,  159. 
Blood  changes  in  diphtheria,  62. 

micrococci  in  the,  32. 
Boissarie  quoted  by  Growers,  cases 
of    paralysis    occurring    simul- 
taneously with  other   cases  of 
diphtheria,  118. 
Boldyrew,  views  of,  47. 
Boracic  acid  in  the  treatment  of 

diphtheria,  194. 
Borax  in  the  treatment  of  diph- 
theria, 193. 
Bosse,  internal  use  of  oil  of  tur- 
pentine, 195. 
Bouchut,  favorable  results  from 
the  use  of  nitrate  of  silver, 
158. 
method  of  intubation  of  the 
larynx  devised  by,  15,  266. 
Boyd,  J.  M.,  veratrum  viride  in 

diphtheria,  209. 
Braddon,   L.,  local  use  of  oil  of 

peppermint,  199. 
Brain,  changes  in,  65. 
Breath,  foetor  of,   in  pharyngeal 

diphtheria,  70. 
Breathing    in    laryngeal   diph- 
theria, 82,  84,  290. 
Bree,  J.,  internal  use  of  cyanide 

of  mercury,  177. 
Bretonneau,    limitations    in  the 
use  of  caustics,  157. 
artificial  production  of  pseu- 
do-membrane, 58. 
syringe  for  nasal  use,  226. 
term     diphtherite    proposed 

by,  1. 
treatises  on  diphtheria  by,  11. 
unsuccessful  attempt  at  inoc- 
ulating animals  by,  26. 
use  of  alum  by,  161. 
Bromine  in  the  treatment  of  diph- 
theria, 184,  196. 
Bronchitis,  catarrhal,  in  diphthe- 
ria, 64. 


INDEX. 


311 


Bronchitis,  diphtheritic,  137,  802. 
pseudo-membranous,  in  diph- 
theria, 64. 
Broncho-pneumonia  in  diphthe- 
ria, 64. 
Brondel,  treatment  of  diphtheria 

by  benzoate  of  sodium,  190. 
Brown,  Dillon,  quoted  by  Jacobi, 
internal  use  of  bichlo- 
ride of  mercury,  175. 
reference  to  bibliography 
on  intubation  prepared 
by,  266. 
statistics    of    intubation, 
297. 
Graham,  parasiticidal  action 
of   benzoate  of   sodium    in 
diphtheria,  190. 
Lenox,   rhinoscopic   view    o'f 
posterior     nares    in    naso- 
pharyngeal diphtheria,  134. 
T.    Clowes,   successful    treat- 
ment by,  213. 
Brunton,  action  of  iron,  201. 

advantages  of  nitrate  of  sil- 
ver, 159. 
on  alcohol,  206. 
Buhl,  lesions  found    in    diphthe- 
ritic paralysis,  66. 
tissue    infiltration    observed 
by,  47. 
Bullard,  W.  E.,  cases  treated  by, 

211. 
Buzzard,    T.,    the    pathology    of 
diphtheritic  paralysis,  117. 

Cadet  de  Gassicourt,  diphthe- 
ritic paralysis  of  the  heart, 
112. 
heart-clots  in  diphtheria,  63. 
albuminuria    in    diphtheria, 
91. 
Caldwell,    W.    C,    local    use    of 
hydronaphthal    with     papain, 
200. 
Calomel,  fumigations  with,  178. 
in  the  treatment  of  diphthe- 
ria, 173. 
Cannula,  tracheal,  251. 
Carbolic  acid,  local  use  of,   180, 

236,  237. 
Cardiac  complications,  symptoms 
of,  93. 
depressants  in  the  treatment 
of  diphtheria,  209. 
Carmichael,     quoted    by     Holt, 

128. 
Carter,  E.  C,  use  of  bichloride  of 

mercury,  175. 
Caselli,  A.,   statistics    of   trache- 
otomy, 245. 


Castleberry,  plan  of  feeding  after 

intubation,  300. 
Casts  in  the  urine,  prognostic  sig- 
nificance of,  92. 
Catheterization  of  the  larynx,  265. 
Causation  of  diphtheria,  16,  259. 
Caustics,  use  of,  in  diphtheria,  157, 
Cautery,  actual,  use  of,  158. 

galvano-,  use  of,  159. 
Cells,  degenerative  metamorpho- 
sis of,  in  diphtheria,  51. 
Chaff ey,  W.  C,  heart-clots  as  a 

cause  of  death,  63. 
Chagin,  Gustav,  statistics  of  trach- 
eotomy in  infants,  246. 
Chapin,  H.  D.,  trypsin  as  a  solv- 
ent   of    false    membrane,    164, 
167. 
Charcot  and  Vulpian,  peripheral 
lesions  in  diphtheritic  paraly- 
sis, 65. 
Chaussier,   on   catheterization  of 

the  larynx,  265. 
Cheyne,  W.  W.,  antiseptic  trach- 
eotomy, 249. 
antiseptic  treatment  employ- 
ed by,  172. 
Childhood,  diphtheria  mainly  a 

disease  of,  16. 
Children,   special  therapeutic  in- 
dications in  the  case  of,  152. 
why  diphtheria  attacks  chief- 
ly, 17. 
Chinoline,  local  use  of,  181,  196. 
Chittenden,    R.  H.,  pepsine  as  a 
solvent  of  false  membrane,  167. 
Chloral  in  the  treatment  of  diph- 
theria, 187,  222. 
Chlorate  of  potassium,    formula 
for  internal  administra- 
tion of,  219. 
in  the  treatment  of  diph- 
theria, 191. 
poisonous  action  of,  191. 
Chloride  of  iron,  formula  for  in- 
ternal     administration 
of,  220. 
internal  use  of,  196,  201. 
limitations  to  its  utility, 
202. 
Chlorine  in  the  treatment  of  diph- 
theria, 183. 
Cholewa,  on  the  local  use  of  men- 
thol, 199. 
Chomel,   epidemic  of    diphtheria 

described  by,  6. 
Cinchona   in  diphtheria,  233. 
Citric  acid,  local  use  of.  199. 
Clark,   C.  C.  P.,   on  the  employ- 
ment of  Monsel's  solution,  161. 
Cleanliness,  necessity  of,  170. 


312 


INDEX. 


Climate  in  relation  to  diphtheria, 

18,  60. 
Clothing,  conveyance  of  the  con- 
tagion of  diphtheria  by,  28. 
disinfection  of,  148. 
Coagula  in  heart  and  large  vessels 

63. 
Coagulation-necrosis,  48. 

caused  by  temporary  cutting 
off  of  the  blood  supply,  58. 
Coffee  in  heart  failure,  233. 
Cohnheim,  production  of  coagula- 
tion-necrosis     by     temporary 
arrest  of  the  circulation,  58. 
Cold,       catching,       membranous 
croup  from,  59. 
favoring     attacks     of    diph- 
theria, 18. 
Colden,     Cadwallader,    epidemic 

of  diphtheria  described  by,  9. 
Cologne  water,  pseudo-membrane 
caused  by  local  application  of, 
57. 
Comstock,  D.  C,  cases  treated  by, 

211. 
Congestion,  pulmonary,  in  diph- 
theria, 64. 
Conjunctivitis,     diphtheritic,  14. 
sj'mptoms  of,  86. 
treatment  of,  257. 
Constitutional     poisoning     from 
concealed  nasal  or  bron- 
chial diphtheria,  99. 
not  dependent  upon  pu- 
trefactive     decomposi- 
tion of  the  false  mem- 
brane, 76. 
Constitutional    symptoms    often 
relieved  by  local  treatment,  102. 
Contagion,    occurrence  of    diph- 
theria by,  24. 
of  diphtheria,  conveyance  of 
by  food  and  drink,  29. 
difference  in  virulence  of, 
in  epidemic  or  sporadic 
and  endemic  cases,  30. 
nature  of,  30. 
retention  of,  in  furniture 
and  clothing,  28. 
Convalescence,  tonics  during,  232. 
Copaiba  in  the  treatment  of  diph- 
theria, 208. 
Copper  sulphate  as  a  caustic  in 

diphtheria,  158 
Corbin,  J.,  mercurial  fumigations, 

178. 
Cornil  and  Babes,  bacteriological 

investigations,  of,  39. 
Corrosive  sublimate,  formulae  for 
the  internal  administration  of, 
221. 


Corrosive  sublimate,  internal  ad- 
ministration of,  175,  241, 
299 
local  use  of,  171,  196. 
Cough  after  intubation,  276. 

in  larvngeal    diphtheria,   82, 
83,  289. 
Croup  and   diphtheria,   question 
of  identity  of,  59,  61,  293. 
catarrhal  and   membranous, 
differential    diagnosis,   136, 
293. 
diagnosis  of,  289. 
intubation  in,   265.     See  In- 
tubation, 
membranous    and  diphtheri- 
tic, differential  diagnosis,  137 
prognosis  of,  296. 
relation  of  season  to,  60. 
simple     membranous,      from 

"  catching  cold,"  59. 
treatment  of,  299. 

after  intubation,  300. 
Croup-kettle,  240. 
Croupal  false  membrane,  48. 
Croupous  inflammation,  49. 

possibility  of  multiple  causes 
for,  42, 
Cubebs  in  the  treatment  of  diph- 
theria, 208. 
Curtis  and  Satterthwaite,  inocu- 
lation experiments  by,  27. 
micro-organisms  in  diphthe- 
ria, 32. 
Cvanosis  in  laryngeal  diphtheria, 
84. 
an  uncertain  indication  of  in- 
tubation, 271. 

Da  Costa,  local  use  of  thymol, 
199. 
ulcero-membranous     angina, 
123. 
Daly,  W.  H  ,  calomel  in  the  treat- 
ment of  diphtheria,  174. 
Dampness    favoring    attacks    of 

diphtheria,  18. 
Darken,  E.  J.,  cases  treated  by, 

211. 
Death  in  laryngeal  diphtheria,  84. 
Deglutition,  difficult,  after  intu- 
bation, 300. 
after  intubation,  not  promi- 
nent feature  in  adults,  305. 
in  diphtheritic  paralysis,  109, 

111. 
management  of,  256. 
Dejerine,  lesions  found  in  diph- 
theritic paralysis,  66. 
Delavan,  D.  Bryson,  anatomy  of 
the  tonsils,  124. 


INDEX. 


313 


Delavan,    D.    Bryson,     constitu- 
tional infection  following  nasal 
diphtheria,  99. 
Delirium,  prognostic  significance 

of,  143. 
Delthil,  account  of  diphtheria  in 
animals  by,  23. 
turpentine    inhalations,    197, 
241. 
Deslandes,  13. 

D'Espine,    A.,   bacteriological  in- 
vestigations of,  39. 
parasiticidal  action  of  salicy- 
lic acid,  181. 
Details,  necessity  of  attention  to, 

153. 
Diagnosis  of  croup,  289. 

of  diphtheria,  121  et  seq. 
Dickinson,  J.,  epidemic  of  diph- 
theria described  by,  8. 
Diet  in  diphtheria,  223,  232. 
Digitalis    in    albuminuria    with 
ursemic  symptoms,  235. 
in  fever,  303. 
in  heart  failure,  233. 
Diphtheria  a  constitutional  dis- 
ease, arguments  in  support 
of,  97. 
a  local  disease,  arguments  in 

support  of,  96. 
ages  of  those  attacked  by,  16. 
albuminuria  in,  89,  302. 
and  croup,  question  of  iden- 
tity of,  59,  61,  293. 
and  follicular  tonsillitis,  dif- 
ferential diagnosis,  130. 
and  membranous  croup,  dif- 
ferential diagnosis,  137. 
and  membranous   pharyngi- 
tis,   differential    diagnosis, 
123. 
and  scarlatina,  differential  di- 
agnosis, 135. 
bronchial,  diagnosis,  137. 

prevention  of,    by  early 

tracheotomy,  249. 
symptoms  of,  85. 
treatment,  302. 
cardiac  complications,  symp- 
toms of,  93. 
classification  of,  68. 
climate  in  relation  to,  18. 
communication  of,  by  a  bite,  4. 

through  the  air,  28. 
constitutional,  alcohol  in  the 
treatment  of,  205. 
recovery  following,  77. 
relapses  in,  78. 
signs    of     approaching 

death  in,  77. 
symptoms  of,  75. 


Diphtheria,  constitutional,  treat- 
ment of,  230. 
contagion  of,  24. 
convalescence  from,  78. 
cutaneous,  89. 

treatment,  258. 
deep,  51. 
definition,  1. 
derivation  of  term,  1. 
diagnosis,  121  et  seq. 
endemic    prevalence,    insani- 
tary   conditions    a    potent 
factor  in,  22. 
epidemics  of,  in  the  middle 

ages,  3. 
eruptions  in,  94. 
etiology  of,  16,  259. 
gangrene  in,  81. 
gangrenous,  prognosis  of,  143. 
histological  changes  in,  51. 
history,  2. 
in  animals,  23. 
incubation  of,  44. 
infection  of,  24. 
influence  of  season  upon  the 

occurrence  of,  19. 
inoculation  of,  26. 
intestinal,  diagnosis  of,  137. 

symptoms  of,  88. 
laryngeal,  diagnosis  of,  289. 

emetics  in,  242. 

intubation  in,  265.  See 
Intubation. 

prevention  of,  235. 

prognosis  of,  296. 

symptoms  of,  82. 

terminations  of,  84. 

tracheotomv  in,  244. 

treatment  of,  235,  299. 

treatment  of,  after  intu- 
bation, 300. 
malignant,  79. 
micro-organisms  in,  31,  259. 
mortality,  statistics  of,  139. 
nasal,  diagnosis  of,  135. 

especially  liable  to  be  at- 
tended with  constitu- 
tional poisoning,  74. 

prognosis  of,  143. 

symptoms,  73. 
nature  of  contagium  of,  30. 
nephritis  in,  89. 
of  the  anus,  88. 
of  the  digestive  tract,  expla- 
nation of  the  rarity  of,  97, 
of  the  ear,  symptoms  of,  85. 
of  the  Eustachian  tubes,  85. 
of  the  eye,  symptoms  of,  86. 

treatment  of,  257. 
of  the  genito-urinary  organs, 


314 


INDEX. 


Diphtheria  of  the  mouth,  75. 

of  the  oesophagus,   diagnosis 
of,  137. 
symptoms  of,  87. 
of  the  stomach,  diagnosis  of, 

137. 
symptoms  of,  88. 
of  the  vulva,  88. 
of  wounds,  89. 
paralysis  following,  108. 
parenchymatous,  51. 
pathology,  46  et  seq. 
pharyngeal,  diet  in,  223. 
symptoms,  68. 

of  catarrhal  stage,  69. 
of    stage    of    pseudo- 
membranous forma- 
tion, 70. 
terminations  of,  72. 
treatment  of  early  stage 
of.  214. 
of  later  stage  of,  229. 
poison  of,  262. 
predisposition,  individual,  or 

family,  to,  18. 
primary  nature  of,  96. 
prognosis  of,  139  et  seq. 
prophylaxis  of,  145  et  seq. 
pulmonary        complications, 

symptoms  of,  93. 
second  attacks  of,  18. 
secondary,  104. 

location  of   pseudo-mem- 
brane in,  107. 
septic,  recovery  following,  77. 
relapses  in,  78. 
signs      of      approaching 

death  in,  77. 
symptoms  of,  75. 
superficial.  51,  78. 
symptoms,  68  et  seq. 
tonsillar,  explanation  of  fre- 
quency of,  56. 
tracheal,  symptoms  of,  85. 
transmission  of,  by  direct  con- 
tact, 25. 
treatment,  150  et  seq. 
two  forms  of,  35. 
vaginal,  88. 

without  a  diphthera,  improb- 
able, 123. 
Diphtheritic  and  scarlatinal    al- 
buminuria,   differences   be- 
tween, 92. 
false  membrane.    See  Pseudo- 
membrane, 
inflammation,  50. 
process,  mode  of  extension  of, 

54. 
paralysis,    108.      See   Paraly- 
sis, diphtheritic. 


Diphtheritic  sore-throat,  a  term 

too  vaguely  applied,  122. 
Diphtheritis,  superficial,  51. 
Diplopia  in  diphtheritic  paralysis, 

109. 
Disinfectants,  how  to  use,  148. 

list  of  necessary,  147. 
Disinfection,  efficiency  of,  in  pro- 
phylaxis, 149. 
instructions  for,  147,  170. 
Dissault,  on  catheterization  of  the 

larynx,  265. 
Donders,     paralysis     of      ciliary 
muscles    following   diphtheria, 
107. 
Douglas,  William,  8. 
Drain-throat,  123. 
Druitt,  Robert,  perchloride  of  iron 

in  diphtheria,  202. 
Duchenne,  use  of  the  faradic  cur- 
rent in  the  dyspnoea  of  diphthe- 
ritic paralysis,  256. 
Dwellings,    insanitary    condition 
of,   favoring  the  occurrence  of 
diphtheria,  21. 
Dysesthesia,  in  diphtheritic  par- 
alysis, 110. 
Dyspnoea  as  an  indication  for  in- 
tubation, 270.     . 
for   the   removal    of    the 
tube    after  intubation, 
278. 
for  tracheotomy,  244. 
from  tumefaction  of  the  ton- 
sils, 291. 
in      diphtheritic      paralysis, 

management  of,  256. 
in  laryngeal   diphtheria,  82, 
84,  290. 


Ear,  diphtheria  of,  symptoms  of, 
85. 

Eau-de-Cologne,  p  s  e  u  d  o-m  e  m- 
brane  caused  by  local  applica- 
tion of,  57. 

Electrical  reactions  in  diphtheri- 
tic paralysis,  114. 

Electricity  in  diphtheritic  paraly- 
sis, 254. 

Emangard,    13. 

Emboli  causing  infarctions  in 
diphtheria,  63. 

Emetics,  failure  of,  in  asphyxia, 
243. 
in  croup,  caution  in  the  use 
of,  242. 

Emmerich,  micro-organism  de- 
scribed by,  35. 

Emphysema,  acute  general,  some- 
times present  in  croup,  271. 


INDEX. 


815 


Emphysema,  pulmonary,  in  diph- 
theria, 64. 

Endemic  prevalence  of  diphthe- 
ria, 22. 

Endocarditis  not  a  frequent  com- 
plication, 64. 

Engelmann,  local  use  of  vinegar, 
199. 

Epidemic  occurrence  of  diphthe- 
ria, 29. 

Epidemics  of  diphtheria  in  the 
middle  ages,  3. 

Epistaxis  in  nasal  diphtheria,  74. 

Epithelial  changes  in  diphtheria 
51. 

Epithelium,  normal,  of  mouth 
and  throat,  impermeable  by 
bacteria,  56. 

Eruptions,  diphtheritic,  94. 

Etiology  of  diphtheria,  16,  259 

Eucalyptus,  vapors  of.  in  the 
treatment  of  diphtheria,  198. 

Eustachian  tubes,  diphtheria  of, 
85. 

Euthanasia  not  always  afforded 
by  tracheotomy,  248. 

Eye,  diphtheria  of  the,  86,  257. 

Fagge,      Hilton,       membranous 
laryngitis  caused  by  local  injury 
57. 
Feeding  after  intubation,  300. 
artificial,      after    intubation, 
301. 
in  diphtheritic  paralysis, 
256. 
error  of  over-,  in  diphtheria, 
223,  232. 
Fever  as    an   indication    for   re- 
moval of  the  tube*  after  in- 
tubation, 279. 
in    constitutional    poisoning, 

76. 
in  pharyngeal  diphtheria  69, 

71,  79. 
not  necessarily  a  sign  of  con- 
stitutional infection,  98. 
prognostic  significance  of,  142. 
treatment  of,  218,  303. 
Fieuzal,   local  use  of    lemon 
juice,  199. 
Foetor  of  the  breath  in  pharyn- 
geal diphtheria,  70. 
Food  and  drink,   aversion  to,  in 
constitutional  poisoning,  77. 
contagion  of  diphtheria  con- 
veyed by,  29. 
to  be  given  at  regular  inter- 
vals, 224. 
Forceps,  tracheal,  253. 
Formulae,  see  under  Treatment. 


Fothergill,    John,    epidemic  de- 
scribed by,  6. 

Fowler,   Geo.  B.,  calomel  in  the 
treatment  of  diphtheria,  174. 

Fox,  quoted  by  Lefferts,  spread- 
ing quinsy,  127. 

Fruitnight,  J.     H.,   internal  use 
of  hyposulphite  of  soda,  183. 

Fumigation  of  rooms,  148. 

Fumigations,  antiseptic,  198. 
mercurial,  178. 

Furniture,  retention  of  the  con- 
tagion of  diphtheria,  in,  28. 

Gag,  mouth,  in  intubation,  266. 
Galvano-cautery,  use  of,  159. 
Gangrene,  occurrence  of,  in  diph- 
theria, 81. 
Gangrenous  diphtheria,  prognosis 

of,  143. 
Gargling,  availability  of,  155. 
Garrotillo,  4. 

Gaucher,  lesions  found   in  diph- 
theritic paralysis,  67. 
Genito-urinary  organs,  diphtheria 

of,  88. 
Gerhardt,  account  of  diphtheria 

in  animals  by,  23. 
Gibney,  quoted  by  Holt,  126. 
Gifford,  H. ,  on  the  Marchand  solu- 
tion of  per-oxide  of  hydrogen, 
189. 
Glands,    swollen,   in    diphtheria, 
treatment  of,  231. 
in  nasal  diphtheria,  74. 
in  pharyngeal  diphtheria,  71. 
Glottis,    intubation  of  'the,    265. 
See  Intubation, 
oedema  of,  mistaken  for  croup, 
292. 
Glycerine,  advantage  of,  in  cover- 
ing the  acridity  of  tincture  of 
iron,  220. 
Gowers,  frequency  of  diphtheritic 
paralysis,  108. 
on  electricity  and  strychnine 
in    diphtheritic    paralysis, 
255. 
v.  Graefe,   diphtheritic  conjunc- 
tivitis described  by,  14. 
Guelpa,    G.,    irrigation     in     the 
treatment  of  diphtheria,210. 
method  of  employing  irriga- 
tion, 218. 
Guersant,  articles  on  diphtheria 

by,  12. 
Guttmann,   G.,  successful  use  of 
pilocarpine,  170. 

Hemorrhages  in  malignant 
diphtheria,  80. 


316 


INDEX. 


Haig-Brown,  quoted  bv  Holt,  126. 
Hanks,  H.  T.,  remarks  by,  211. 
Hatfield,  M.  P.,  use  of  peroxide  of 

hydrogen,  188. 
Health  Department  of  New  York 
City,  instructions  for  disin- 
fection, 147,  170. 
statistics  of  diphtheria,  16,  19, 
139 
Heart,  affections  of,  in  diphtheria, 
93. 
changes  in  diphtheria,  63. 
clots  as  a  cause  of  death  in 

diphtheria,  63. 
diphtheritic  paralysis  of,  110. 
failure,  treatment  of,  233,  257. 
Henoch,  employment  of  galvano- 
cautery  by,  159. 
mortality  of  diphtheria,  140. 
Henry,  F.   P.,  hypodermic  injec- 
tions of  bicyanide  of  mercurv, 
178. 
Hepatic  lesions  in  diphtheria,  65. 
Herpetic  sore  throat,  diagnosis  of, 

from  diphtheria,  123. 
Heslop,  15. 
Hesse,   P.,  local  use  of  bromine, 

184. 
Heubner,  O.,  absence  of  bacteria 
in      artificially      produced 
pseudo-membrane,  59. 
production  of  false  membrane 
by  temporary  arrest  of  cir- 
culation in  the  part,  58. 
scarlatinal  diphtheria,  106. 
Hiller.  local  use  of  bromine,  184. 
Hippocrates,    on   catheterization 

of  the  larynx,  265. 
Hirsch,  relation  of  croup  to  the 

season,  60. 
Histological  changes  in  diphthe- 
ria, 51. 
History  of  diphtheria,  2. 

of  intubation,  265. 
Hoarseness  in  croup,  290. 
v.     Hoffmann-Wellenhoff,    bacte- 
riological investigations  of,  40. 
Hofmokl,  use  of  peroxide  of  hy- 
drogen, 188. 
Holt,  L.  Emmet,  croupous  tonsil- 
litis, 128. 
follicular  tonsillitis  and  diph- 
theria not  related,  126. 
necessity  of  correct  diagnosis 
in  estimating  the  results  of 
treatment,  154. 
Home,  Francis,  treatise  on  croup 

by,  6. 
Huber,  F.,  bichloride  of  mercury, 

175,  221. 
Hueter,  27. 


Hullmann,   therapeutic  value  of 

chlorate  of  potassium,  192. 
Humidity    favoring    attacks     of 

diphtheria,  18. 
Hutton,  T.  J.,  use  of  nitrate  of 

silver  by,  159. 
Hvdrogen  peroxide,  local  use  of, 

188,  222. 
Hydronaphthal,  local  use  of,  200. 

Immunity,   temporary,    afforded 
by  one  attack  of  diphtheria,  18. 
Incubation,  period  of,  44. 
Indications  to    be    met    in    the 

treatment  of  diphtheria,  150. 
Infection,   general,   mode  of  pro- 
duction of,  62. 
not  necessary  to  the  produc- 
tion of  croupous    or  diph- 
theritic   inflammation,    57, 
60. 
occurrence  of  diphtheria  by, 
24. 
Inflammation,  croupous,  49. 

diphtheritic,  50. 
Injection,     hypodermic,   of  mer- 
curial salts,  178. 
nasal,  fluids  for,  228. 
Inoculation,       diphtheria      com- 
municated by,  26. 
with  cultures  of  Loeffler's  ba- 
cillus, 259. 
Insanitary    conditions    favoring 
the  occurrence  of  diphtheria.  21. 
Internal   administration  of  rem- 
edies, 155. 
Intestines,  diphtheria  of  the,  diag- 
nosis of,  137. 
symptoms  of,  88. 
diphtheritic  paralvsis  of  the, 
113. 
Intubation   in  croup  and    other 
acute  and  chronic  forms  of 
stenosis  of  the  larynx,  265. 
accidents  and  dangers  of,  280. 
abrasious  of  mucous  mem- 
brane, 288. 
accumulation  of  tenacious 

mucus,  285. 
contact  of  tube  with  the 
anterior     Avail     of     the 
larynx  or  trachea,  281. 
coughing  out    the   tube, 

285. 
false  passage,  280. 
passage    of   extractor    beside 

the  tube,  286. 
pushing    down    false    mem- 
brane, 281. 
tumefaction  of  epiglottis  and 
aryepiglottic  folds,  285. 


INDEX. 


317 


Intubation,  ulceration  caused  by 
the  tube,  288. 
caution  as  to  the  manner  of 
extraction  of  the  tube,  277. 
cough  after,  276 
defects  in  the  tubes,  287. 
description    of    instruments 

for,  266. 
difficulty  of  deglutition  after, 

300. 
feeding  after,  300. 
history,  265. 
in  chronic  stenosis  in  children, 

306. 
in  the  adult,  303. 
indications  for,  270. 

for  removal  of  the  tube, 
278. 
instruments  for,  266. 

in  adults,  304. 
introduction  of  the  tube,  274. 
method  of  operation,  272. 
obstruction  of  the  tube,  278. 
practice  on  larynx  of  a  small 

animal  useful,  276. 
removal  of  obturators,  275. 
statistics  of,  297. 
time  for  performing,  270. 

for    removing    the   tube, 

278. 
required  for,  280. 
treatment  of  croup  after,  300. 
withdrawal  of  the  tube,  275. 
Inunctions,  mercurial,  177. 
Iodine,  use  of,  in  diphtheria,  185, 

222. 
Iodoform,  local  use  of,  186,  222. 
Iodol,  187. 

Ipecacuanha,  syrup  of,  in  laryn- 
geal diphtheria,  242. 
Iron,  chloride  of,  formula  for  in- 
ternal     administration 
of,  220. 
internal    use  of,   in    the 
treatment    of    diphthe- 
ria, 196,  201. 
limitations  to  its  utility, 

202. 
local  employment  of,  162. 
solution  of  the  subsulphate, 
local  employment  of,  161. 
Irrigation   in    the    treatment   of 
diphtheria,  210,  218. 
means  of  effecting,  156. 
Irritants,  topical,  in  diphtheritic 
•  paralysis,  256. 
Irritation,  necessity  of  avoiding, 

in  the  treatment,  152. 
Isolation,    efficiency    of,    in    pro- 
phylaxis, 149. 
necessity  of,  146. 


Jaborandi,  use  of,  to  loosen  the 

false  membrane,  169. 
Jacobi,    A.,  chloride  of    iron    in 
diphtheria,  203. 

diphtheritic  paralysis  not  the 
result  of  the  same  cause  in 
every  case,  120. 

disadvantages  of  the  employ- 
ment of  steam,  164. 

internal  use  of  bichloride  of 
mercury,  175. 

inunctions  with  oleate  of  mer- 
cury, 178. 

method  of  treatment  advo- 
cated by,  212. 

tolerance  of  corrosive  subli- 
mate by  children,  241. 

use  of  papayotin,  169. 

Keating,  local  use  of  tincture  of 

iodine,  185. 
Kidd,     Percy,    lesions    found    in 

diphtheritic  paralysis,  67. 
Kidneys,  changes  in,  65. 
Klebs  and    Loeffler,   bacillus  of, 

259. 
Klebs,   micro-organisms  in  diph- 
theria, 32. 
microsporon    diphtheriticum 
of,  35. 
Klingensmith,  J.  P.,  large  doses 
of  calomel  in  the  treatment  of 
diphtheria,  174. 
Knaggs,  H.   V.,   internal  use   of 

sulphur,  182. 
Knee-jerk,     loss     of,      following 

diphtheria,  114. 
Koch,  antiseptic  action    of  ben- 
zoate  of  sodium,  190. 
antiseptic    action     of    lime- 
water,  166. 
bactericidal    action     of     bi- 
chloride of  mercury,  171. 
Kotzuski,  calomel  in  the  treatment 
of  diphtheria,  174. 

Lactic  acid  as  a  solvent  of  false 

membrane,  164. 
Landouzy,  influence  of  age  in  the 
occurrence  of  diphtheritic  par- 
alysis, 100. 
Laryngeal  diphtheria.    See  Diph- 
theria. 
Laryngismus  stridulus,  mistaken 

for  croup,  292. 
Laryngitis,  catarrhal  and  mem- 
branous, differential    diag- 
nosis, 136. 
croupous     and    diphtheritic, 
differential  diagnosis,  137. 


318 


INDEX. 


Laryngitis,  membranous,  of  non- 
specific origin,  57,  60. 
syphilitic,  false  membrane  in, 
295. 
Laryngoscope,  use  of,  in  intuba 

tion  in  the  adult,  304. 
Laryngoscopic     appearances     in 
diphtheritic    paralysis    of    the 
vocal  cords,  111. 
Larynx,    chronic    stenosis  of.   in 
children,  intubation  for,S.0o. 
downward  movement  of,  dur- 
ing   inspiration    pathogno- 
monic of  obstruction,  271. 
extension  of  membrane  to  the, 

prevention  of,  235. 
intubation  of,  265. 
lumen  of  subglottic  division 

of  the,  268. 
stenosis  of,  intubation  in,  265. 
Lax,    formula    for    the    employ- 
ment of  pilocarpine,  170. 
Lefferts,  Geo.  M.,  follicular  ton- 
sillitis, 127. 
Le  Gendre,  formula  for  the  em- 
ployment of  borax,  193. 
local  use  of  iodoform,  186. 
Lemon  juice,  local  use  of,  199. 
Lepine,  lesions  found  in  diphthe- 
ritic paralysis,  66. 
Letzerich,  internal  use  of  benzo- 
ate  of  sodium,  190. 
tilletia  diphtheritica  of,  35. 
zygodesmus  fuscus  of,  31. 
Leyden,  lesions  found  in  diphthe- 
ritic paralysis,  66. 
Liblond,  local  use  of  resorcine,  182. 
Lime,  slacking,  for  inhalation  in 

laryngeal  diphtheria,  241. 
Lime-water      and      carbolic-acid 
spray  in  laryngeal  diphthe- 
ria, 236,  237. 
as  a  solvent    of    false    mem- 
brane, 164. 
therapeutic  value  of,  in  diph- 
theria, 165. 
vapor  of,  is  simply  steam,  164. 
Liouville,  lesions  found  in  diph- 
theritic paralysis,  66. 
Liquor  sodse  chlorate,  local  use  of, 
184. 
potass*  as  a  local  application, 
166. 
Liver,  changes  in,  in  diphtheria, 

65. 
Local  applications,  156. 
Local  disease,  diphtheria  prima- 
rily a,  96. 
Locomotor  ataxia  and  diphtheri- 
tic paralysis,  differential   diag- 
nosis, 138. 


Loeffler,  bacillus  of,  259. 

Loeffler,  Friederich,  bacterio- 
logical investigations  of,  36. 

Loomis,  A.  L. ,  heart-clots  in  diph- 
theria, 63. 

Lorain  and  Lepine,  lesions  found 
in  diphtheritic  paralysis,  66. 

Lovett  and  Munro,  statistics  of 
tracheotomy,  245,  246,  247,  248. 

Lunar  caustic,  local  applications 
of,  157,  159. 

Lungs,  affections  of,  complicating 
diphtheria,  93. 
changes  in,  in  diphtheria,  64. 

Lunin,  comparative  statistics  of 
the  results  of  treatment  by  va- 
rious remedies,  196. 

McDonnell,  R.  L.,  loss  of  knee- 
jerk  in  diphtheria,  115. 
Mackenzie,  early  advocacy  of  the 
topical  use  of  nitrate  of  sil- 
ver by,  12. 
use  of  nitrate  of  silver  intro- 
duced by,  157. 
Mackenzie,  Morell,  confluent  her- 
pes of  the  throat,  123. 
inadequacy     of     medical 
treatment       alone      in 
laryngeal      diphtheria, 
244. 
instances   of    varying 
periods  of  incubation  in 
diphtheria,  44. 
Maingault,  diphtheritic  paralysis 

described  by,  14. 
Malignant  diphtheria,  79. 
Marchand,  solution  of  peroxide  of 

hydrogen,  188. 
Mason,  local  use  of  permanganate 

of  potassium,  188. 
Membrane,    false.      See  Pseudo- 
membrane. 
Mendel,   lesions    found  in    diph- 
theritic paralysis,  67. 
Menthol,  local  use  of,  199. 
Mercier,   A.,  choral  in  the  treat- 
ment of  diphtheria,  187. 
Mercurial  ointment,  inunctions  of, 

177. 
Mercury,   acid    nitrate    of,   as    a 
caustic  in  diphtheria,  158. 
bichloride  of,  formulae  for  the 
internal  administration 
of,  221. 
in  diphtheria,  299. 
in   laryngeal    diphtheria, 

241. 
local  use  of,  171,  196. 
.     biniodide  of,  177,  222. 
cyanide  of,  171,177,  222. 


INDEX. 


319 


Mercury,  fumigations  of,  178. 
iodides  of,  171. 
mild   chloride  of,  internally, 

173. 
oleateof,  inunctions  with,  177. 
salts  of,  fumigations  with,  178. 
hypodermic  injections  of, 

178. 
injurious  effects  from  the 

abuse  of,  179. 
internal  use  of,  173,  222. 
local  use  of,  171,  222. 
may  aggravate  constitu- 
tional symptoms,  179. 
yellow    sulphate    of,    as    an 
emetic    in  laryngeal   diph- 
theria, 242. 
v.  Mering,  quoted  by  Seeligmul- 

ler,  192: 
Metschnikoff,  destruction  of  bac- 
teria by  the  cells,  171. 
Meyer,  lesions  found  in  diphthe- 
ritic paralysis,  67. 
Micrococcus  of  Oertel,  31. 
Micro-organisms    in    diphtheria, 
31,  259. 
in  the  blood  of  diphtheritic 
patients,  32.  ■ 
Milk,  contagion  of  diphtheria  con- 
veyed by,  29. 
Milk  diet  in  pharyngeal  diphthe- 
ria, 223. 
Monsel's  solution,   local  employ- 
ment of,  161. 
Moore,   W.    0.,   rarity  of   ocular 

diphtheria,  87. 
Mott,  lesions  found  in  diphtheritic 

paralysis,  67. 
Mouth,  diphtheria  of  the,  75. 
Mouth-gag  in  intubation,  266. 
Mundie,  GL,  ethereal  solution  of 

iodoform  for  local  use,  187. 
Mufioz,  apomorphine  in  laryngeal 

diphtheria,  243. 
Murray    Gribbes,    J.,    eucalyptus 
vapors,  198. 

Nares,  cleansing  of  the,  225. 
Nasal  diphtheria,  diagnosis  of,  135. 
especially    liable     to    be 
attended  with  constitu- 
tional poisoning,  74.    • 
prognosis  of,  143. 
symptoms,  73. 
treatment  of,  224. 
Nature,   primary,  of  diphtheria, 

96. 
Nephritis  in  diphtheria,   65,   89, 

302. 
Nerve  lesions  in  diphtheritic  pa- 
ralysis, 65,  115. 


Neuritis,  interstitial,  in  diphthe- 
ritic paralysis,  116. 
migrans  found  by  Leyden  in 

diphtheritic  paralysis,  66. 
parenchymatous,  in  diphthe- 
ritic paralysis,  115. 
Nicati,  account  of  diphtheria  in 

animals  by,  23. 
Nitrate  of  silver,    local   applica- 
tions of,  157,  159. 
Nitric  acid  as  a  caustic  in  ("iph- 

theria,  158. 
Noel,  internal  use  of  borax,  194. 
Northrup,  W.  P.,  examination  of 

false  membrane  by,  296. 
Norwood's  tincture  of  veratrum 

viride  in  diphtheria,  209. 
Nuclei,     degenerative     metamor- 
phosis of,  in  diphtheria,  52. 


Oatman,  E.  L.,  local  use  of  bi- 
chloride of  mercury,  176. 
CVDwyer,  Joseph,  dose  of  bichlo- 
ride of  mercury  in   croup, 
241. 
emetics  in  laryngeal  diphthe- 
ria, 242. 
method  of  intubation  of  the 

larynx  devised  by,  15. 
quoted    by    Jacobi,    internal 
use  of  bichloride  of  mercury, 
175. 
(Edema   in   diphtheritic  albumi- 
nuria, 92. 
of    the  glottis    mistaken   for 
croup,  292. 
Oertel,  M.  J.,  artificial  production 
of  false  membrane,  58. 
bacteriological  investigations 

of,  40. 
histological  changes  in  diph- 
theria, 51. 
inoculation   experiments  by, 

27. 
lesions  found  in  diphtheritic 

paralysis,  66. 
micrococcus  of,  31. 
warm     vapor    recommended 
by,  163. 
(Esophageal  diphtheria,   diagno- 
sis of,  137. 
explanation  of  rarity  of,  98. 
symptoms  of,  87. 
usually  secondary,  107. 
Ory,    formula  for   local    applica- 
tions of  salicylic  acid,  181. 
Otitis  media,  diphtheritic.  85. 
Oxygen  in  the  treatment  of  diph- 
theria, 188 
Ozone,  inhalations  of,  189. 


320 


INDEX. 


Pain  in   pharyngeal  diphtheria, 

70. 
Palate,  soft,  diphtheria  of,  68. 

paralysis  of,  108. 
Papayotin  as  a  solvent  of  false 

membrane,  168,  200. 
Paralysis,     acute    atrophic    and 
diphtheritic,  differential 
diagnosis,  138. 
beginning  in  the  extremities 
after  cutaneous  diphtheria, 
116. 
cardiac,  treatment  of,  257. 
diphtheritic,  108. 

albuminuria  in,  115. 
causation  of,  117. 
diagnosis  of,  188. 
disturbances  of  vision  in, 

109. 
duration,  108-114. 
early  mention  of,  5  et  seq. 
electricity  in,  254. 
experimental   production 

of,  261. 
involving  the  extremities, 

110. 
nerve  lesions  in,  115. 
of  special  senses,  113. 
of  the  bladder,  113. 
of  the  heart,  110. 

treatment  of,  257. 
of  the  intestines,  113. 
of  the  larynx,  110. 
of  the  muscles  of  the  neck 

and  trunk,  111. 
pathology,  65,  115. 
post-mortem  changes  in 

65. 
prognosis  of,  144. 
strychnine  in,  255. 
symptoms,  108. 
tendency  to  spontaneous 

recovery,  254. 
treatment,  254, 
Pathology    of    diphtheria,   46    et 

seq. 
Paulinus,  account  of  diphtheria 

in  animals  by,  24. 
Pepper,   W.,  internal  use  of  bi- 
chloride of  mercury,  175. 
Peppermint,  oil  of,  local  use  of, 

199. 
Pepsin  as  a  solvent  of  false  mem- 
brane, 166. 
Permanganate  of  potassium,  local 

use  of,  188. 
Peroxide  of  hydrogen,  local  use 

of,  188-222. 
Pharyngeal  diphtheria,   mild  or 
benign  form,  symptoms 
of,  72. 


Pharyngeal    diphtheria,     severe 

form,  symptoms  of,  72. 

symptoms     in     stage    of 

pseudomembranous 

formation,  70. 

symptoms     of     catarrhal 

stage,  69. 
terminations  of,  72. 
treatment  of,  214,  229. 
Pharynx  and  soft  palate,  diph- 
theria of,  symptoms,  68. 
Pierret,   lesions    found    in  diph- 
theritic paralysis,  66. 
Pilocarpine,  use  of,  169. 
Pitres,  lesions  found  in  diphthe- 
ritic paralysis,  67. 
Plenio,  statistics  of  tracheotomy, 
•    245. 

use  of  iodoform   in  diphthe- 
ritic invasion  of  the  trache- 
otomy wound,  187. 
Pneumonia  in  diphtheria,  64. 
Poison,  diphtheritic,  262. 

channels  of  absorption  of, 
62. 
Potash,  caustic,  local  use  of,  in 

diphtheria,  158. 
Potassium,  chlorate,  formula  for 
internal  administration 
of,  219. 
in  the  treatment  of  diph- 
theria, 191. 
poisoning  by,  191. 
permanganate,   local   use  of, 
188. 
Poultry,  diphtheria  in,  23. 
Powell,  Seneca  D.,  inhalations  of 

ozone  in  diphtheria,  190. 
Predisposition,  individual  or  fam- 
ily, to  diphtheria,  18. 
Primary  nature  of  diphtheria,  96. 
Prognosis  of  diphtheria,  139  etseq. 
Prophylaxis    of    diphtheria,    145 
et  seq. 
of  laryngeal  diphtheria,  235. 
Prudden,  T.  M. ,  action  of  carbolic 
acid   in  inflammatory  con- 
ditions ,180. 
etiology  of  diphtheria,  263. 
Pseudo-membrane,    agents    used 
for  the  destruction  of,  162. 
artificial  production  of,  in  an- 
imals, 58. 
croupal,  48. 
diphtheritic,  49. 
diphtheritic,   appearance    of, 

70. 
description  of,  46. 
distribution  of,  69. 
extraction  of,   from  the  tra- 
chea, 282. 


INDEX. 


321 


Pseudo-membrane,  formation  of, 
through  coagulation-necro- 
sis, 48. 
in  "croupous  tonsillitis,"  128. 
in  syphilitic  laryngitis,  296. 
necessity   of    removal    of,    in 

nasal  diphtheria,  225. 
production  of,  46. 

as  a  result  of  local  injury, 

57. 
by  temporary  cutting  off 
of  blood  supply,  58. 
pushed  down  by  tube  in  in- 
tubation, 287. 
solvents  of,  163. 
the    pathognomonic   sign    of 
diphtheria,  123. 
Ptomaines,  action  of,  41,  117. 
Pulse  in  constitutional  poisoning, 
■    76. 
in  pharyngeal  diphtheria,  69, 

71. 
prognostic  significance  of,  143. 
Purpura  hemorrhagica  in  diph- 
theria, 80,  95. 
prognostic  significance  of 
143. 

Quinine  in  the   later  stages  of 
diphtheria,  233. 
in  the  treatment  of  diphthe- 
ria, 204. 
seldom  useful  as   an  antipy- 
retic in  diphtheria,  219. 
Quinoline    in    the    treatment    of 

diphtheria,  181,  196. 
Quinsy,  spreading,  127. 

Rachford,  B.  K.,42. 

Ranke,  H.,  statistics  of  tracheot- 
omy, 245. 

Reactions,  electrical,  in  diphthe- 
ritic paralysis,  114. 

Rectum,  feeding  by  the,  224,  301. 

Reed,  unusual  order  of  occurrence 
of  diphtheritic  paralysis,  113. 

Reflex,   patellar    tendon,  loss  of, 
following  diphtheria,  114. 

Reinard  on  strychnine  in    diph- 
theritic paralysis,  255. 

Relapses,  78. 

Remedies,    modes  of  employing, 
155. 
to  be  given  at  regular  inter- 
vals, 224. 

Renault,    P.,  rapid  tracheotomy, 
252. 

Renou,     method     of     antiseptic 
serotherapy,  198. 

Resorcine,  local  use  of,  182,196. 
21 


Respiration,  artificial,  in  diphthe- 
ritic paralysis,  256. 
character      of,    in    laryngeal 
diphtheria,  82,  84,  290. 
Rhinoscopic    view    of    posterior 
nares  in  naso-pharyngeal  diph- 
theria, 134. 
Rindfleisch,  34,  48. 
Robinson,  A.   R.,   quoted    by  J. 

Lewis   Smith,  247. 
Robinson,  Beverly,  heart-clots  as 

a  cause  of  death,  63. 
Rockwell,  A.  D.,  112,  254. 
Roese's  treatment  of  diphtheria, 

195. 
Roser,  antiseptic  tampon  of  the 
trachea,  249. 
dislodgment    of    false    mem- 
brane   below    the    trachea 
tube,  253. 
Rossbach,    use    of    papayotin 

locally,  169. 
Rothe,  C.  Gr.,  internal  use  of  binio- 

dide  of  mercury,  177. 
Roux,  E.,  and  Yersin,  A.,  on  the 

etiology  of  diphtheria,  259. 
Rural  districts,  greater  fatality  of 
diphtheria  in,  21. 


Salicylate  of  sodium  as  an  anti- 
pyretic, 218. 
Salicylic  acid,  formula  for  inter- 
nal   administration   of, 
220. 
local  use  of,  180. 
Salter,  J.  H.,  29. 

Sanne,  alleged  analogy  between 

diphtheria  and  syphilis,  103. 

cubebs  in    the    treatment  of 

diphtheria,  209. 
diphtheritic  eruptions,  94. 
frequency  of  albuminuria,  90. 
diphtheritic  paralysis,  180, 
heart-clots  in  diphtheria, 
63. 
isthmus  of  the  thyroid,  251. 
mortality  of    diphtheria   fol- 
lowing measles,  107. 
diphtheritic  albuminuria, 
91. 
proportion  of  recovery,  with- 
out operation,  in  croup,  244. 
rapid  tracheotomy,  252. 
relation  of  season  to  the  re- 
sults of  tracheotomy,  247. 
statistics  of  tracheotomy,  246. 
views  of,  as  to  the  primary 
nature  of  diphtheria,  97,  99. 
Satlow,  internal  use  of  oil  of  tur- 
pentine, 195. 


322 


INDEX. 


Satterthwaite,  27,  32. 
Scarlatina  and  diphtheria,  differ- 
ential diagnosis,  135. 
diphtheria  secondary  to,  104. 
nature  of  pseudo-membrane 
in,  104. 
Schmiedler,  local  use  of  oil  of  tur- 
pentine, 195. 
Schiiler,   comparative    effects    of 
chlorate  of  potassium,  carbolic 
acid  and  salicylic  acid,  181. 
Season  in  relation  to  croup,  60. 
to  diphtheria,  19. 
to  the  results  of  trache- 
otomy, 246. 
Secondary  diphtheria,  104. 
S6e,  Germain,  14,  25. 
Seeligmuller,  H.,  chlorate  of  po- 
tassium, 192. 
electricity  in  diphtheritic  par- 
alysis, 255. 
Seifert,  O.,  use  of  chinoline,  181. 
Selden,  H.,  use  of  cyanide  of  mer- 
cury, 177. 
Senator,  32. 

Sensory  disturbances  in  diphthe- 
ritic paralysis,  110. 
Settegast,  statistics  of  tracheoto- 
my, 246. 
Severino,  5. 
Sgambatus,  5. 
Shirres,   George,  use  of  iodoform 

after  tracheotomy,  186. 
Sigel,  A.,   internal  use  of  oil  of 

turpentine,  195. 
Silver  nitrate,  local  applications 

of,  157,  159. 
Simon,    Jules,    method    of   local 

treatment  of  diphtheria,  «199. 
Skin,  diphtheria  of  the,  89,  258. 
eruptions  on  the,  in  diphthe- 
ria, 94. 
Sleep,  necessity  of,  303. 
Smith,  A.,  15. 
Smith,    A.    H.,    examination    of 

author's  cases  by,  212. 
Smith,    J.    Lewis,   action    of 
ptomaines  in  the  prod- 
uction   of    diphtheritic 
paralysis,  119. 
addition  of  liquor  potassee 
to    lime  -  water   recom- 
mended by,  166. 
condition  of  the  patient  as 
affecting  the  results  of 
tracheotomy,  247. 
efficiency     of    lime-water 
not  destroyed   by    car- 
bonic acid,  165. 
experience  with  alcohol  as 
a  stimulant,  207. 


Smith,  J.  Lewis,  influence  of  al- 
buminuria    upon     the 
mortality  from  diphthe- 
ria, 92. 
follicular    tonsillitis    and 
diphtheria  not  related, 
126. 
frequency  of  albuminaria, 
90. 
Smith,    S.  W.,   syringe  for  nasal 

use,  226. 
Snow,  H.  L.,  internal  use  of  sul- 
phurous acid,  183. 
Sodium  benzoate  in  the  treatment 
of  diphtheria,  190,  222. 
biborate  in  the  treatment  of 

diphtheria,  193. 
bicarbonate,  local  application 

of,  166. 
hyposulphite,  internal  use  of, 

183,  222. 
salicylate,  as  an  antipyretic, 
218. 
Soil  in  relation  to  diphtheria,  20. 
Solis-Cohen,    J.,     herpetic    sore- 
throat,  123. 
on  the  local   employment   of 
chloride  of  iron,  162. 
Solis-Cohen,  S.,  drain-throat,  123. 
Sore    throat,  common    membra- 
nous, diagnosis  of,  from  diph- 
theria, 123. 
Spain,  great  epidemic  of  diphthe- 
ria in,  4. 
Spalding,  G.  A.,  quoted  by  Holt, 

126. 
Specifics  in  the  treatment  of  diph- 
theria, 208. 
Spinal  cord,  lesions  of,  in  diph- 

ritic  paralysis,  66. 
Spleen,  changes  in,  65. 
Spray,  antiseptic,  in  the  preven- 
tion of    laryngeal   involve- 
ment, 236. 
method  of  application  in  la- 
ryngeal diphtheria,  238. 
Spraying,  advantages  of,  155. 
Sprays  in  the  treatment  of  diph- 
theria, 215. 
Squills,   syrup    of,    in    laryngeal 

diphtheria,  242. 
Starr,  epidemic  of  diphtheria  de- 
scribed by,  6. 
Statistics,  comparative,  of  the  re- 
sults of   treatment    by    bi- 
chloride of  mercury,  chlor- 
ide of  iron,  chinoline,  resor- 
cin,   bromine,  and  turpen- 
tine, 196. 
mortality  of    diphtheria,   91, 
139. 


INDEX. 


323 


Statistics  of  diphtheria  in  regard 
to  age  of  occurrence,  1G. 
of    diphtheria    in   regard  to 

season,  19. 
of  intubation,  297. 
of  tracheotomy,  245. 
Steam,  inhalations  of,  for  loosen- 
ing the  false  membrane,  163. 
in   laryngeal  diphtheria,  239. 
Steam-atomizer,  239. 
Stenosis  of  the  larvnx,  intubation 

in,  265. 
Steudener,  views  of,  47. 
Stimulants,  alcoholic,  in  diphthe- 
ria, 204. 
in  heart-failure,  233. 
in   laryngeal    diphtheria, 
243. 
Stohr,  Ph.,  peculiarity  of  the  ton- 
sillar epithelium,  56. 
Stomach,  diphtheria  of,  diagnosis, 
137. 
symptoms  of,  88. 
usually  secondary,  107. 
Strabismus    in  diphtheritic  par- 
alysis, 109. 
Streptococci    in    diphtheria,   36, 

264. 
Strychnine  in   diphtheritic  par- 
alysis, 255. 
in  the  later  stage  of  diphthe- 
ria, 233. 
Stumpf,  J.,  use  of  bichloride   of 

mercury,  176. 
Sulphur,  employment  of,  182,  222. 

fumigation  with,  148. 
Sulphurous  acid,  internal  use  of, 

183,  222. 
Symptoms,  68  et  seq. 
Syphilis  and  diphtheria,  alleged 

analogy  between,  103. 
Syphilitic  laryngitis,  false  mem- 
brane in,  295. 
stenosis  of  the  larynx  in  chil- 
dren, 307. 
Syringe  for  nasal  use,  227. 
Syringing  the  nares,  method  of, 

Tactile  sensation,   disturbances 
of,    in    diphtheritic    paralysis, 
110. 
Talamon,      micro-organism      de- 
scribed by,  35. 
Tannin,  local  employment  of,  161. 
Tedeschi,  employment  of  galvano- 

cautery  by,  159. 
Temperature     in    constitutional 
poisoning,  76. 
in  pharyngeal  diphtheria,  69, 
71,  79" 


Tendon  reflex,  patellar,    loss  of, 

following  diphtheria,  114. 
Therapeutics  of  diphtheria,    150 

et  seq. 
Thomson,    "W.    H.,    action   of 
ptomaines  in  the    produc- 
tion of  diphtheritic  paraly- 
sis, 118. 
management  of   dyspnoea  in 

diphtheritic  paralysis,  256. 
on  the  treatment  of  diphthe- 
ritic paralysis,  256. 
use  of  bromine  in  diphtheria, 
184. 
Throat,  confluent  herpes  of  the, 
diagnosis  of,  from  diphthe- 
ria, 121. 
inspection  of  the,  in  a  case  of 
suspected  diphtheria,  121. 
Thursfield,  N.  M.,  16,  20. 
Thymol,  local  use  of,  199. 
Thromboses,  venous,  in  diphthe- 
ria, 63. 
Tonics  in  the  later  stage  of  diph- 
theria, 232. 
Tonsillar      diphtheria,     explana- 
tion of  frequency  of,  58. 
Tonsillitis,  acute  follicular  or  lac- 
unal,  124. 
diagnosis  of,  from  diphtheria, 

130. 
croupous,  128. 

follicular,   contagiousness  of, 
124. 
Tonsils,  frequency  of  diphtheria 
of  the,  68. 
openings    in   the  epithelium 

covering  the,  56. 
tumefaction  of,  mistaken  for 
croup,  291. 
Trachea,   antiseptic    tampon    of 
the,  249. 
extraction  of  false  membrane 

from,  282. 
lumen  of,  compared  with  that 
of  larynx,  269. 
Tracheal    diphtheria,    symptoms 
of,  85. 
tube,  251. 
Tracheotomy,  244. 

after-treatment,  252. 
antiseptic,  in  the  prevention 
of  bronchial  diphtheria,  249. 
conditions    affecting  the  re- 
sults of,  245. 
early,  advantages  of,  248. 
operation  of,  250. 
rapid  operation,  252. 
statistics  of,  245. 
Treatment,  150  et  seq. 
actual  cautery,  158. 


324 


INDEX. 


Treatment,  agents  for  the  destruc- 
tion of  false  membrane,  162. 
alcohol,  204,  233,  243. 
alum,  161. 
antifebrin,  219,  303. 
antipyretics  in  the  early  stage 
of   pharyngeal   diphtheria, 
21S 
antipyrin,  219,  303. 
antiseptic  serotherapy,  197. 
antiseptics,  147,  170. 
astringents,  161. 
author's  method  of,  210. 
benzoate  of  sodium,  190,  222. 
bichloride    of    mercury,    171, 

175,  196,  221,  241,  299. 
boracic  acid,  194. 
borax,  193. 

bromine,  locally,  184,  196. 
calomel,  173,  178. 
carbolic  acid,  locally,  180,  236. 
cardiac  depressants,  209. 
caustics,  157. 

chinoline,  locally,  181,  196. 
chloral,  187,  222. 
chlorate  of  potassium,  191,  219. 
chloride  of  iron,  162,  196,  201, 

220. 
chlorine,  locally,  183. 
citric  acid,  locally,  199. 
coffee,  233. 
copaiba,  208. 
copper  sulphate,  158. 
cubebs,  208. 
disinfectants,  147. 
emetics,  242. 
eucalyptus  vapors,  198. 
Formulae  : 

antiseptic  fumigations,  198. 
benzoate  of  sodium  solution 

for  internal  use,  190. 
bicyanide    of    mercury   for 

hypodermic  use,  178. 
biniodide  of  mercury  for  in- 
ternal use,  177. 
borax,  chlorate  of  potassium 
and  carbolic  acid,  for  local 
use,  193. 
bromine   solution  for  local 

use,  184. 
bromine  solution  (Lawrence 

Smith's),  185. 
carbolic  acid  and  lime-water 

spray,  215. 
chinoline  solution  for  local 

use,  182. 
chlorate  of  potassium  mixt- 
ure, 219. 
chloride  of  iron  mixture,  220. 
corrosive  sublimate  for  in- 
ternal administi'ation,  221. 


Formulae : 

cyanide  of  mercury  for  in- 
ternal use,  177. 
hydronaphthal  with  papain 

for  local  use,  200. 
iodine,  chloride  of  iron,  and 
carbolic  acid,  for  local  use, 
185. 
iodoform  solution  for  local 

use,  186. 
papayotin  solution  for  local 

use,  169. 
pepsin  solution  for  local  ap- 
plication, 167. 
pilocarpine  solution  for  in- 
ternal use,  170. 
salicylic  acid  and  sulphite  of 
soda  mixture,  220. 
solution  for  local  use,  181. 
sulphur  mixture  for  internal 

use,  183. 
thymol  gargle  or  spray,  199. 
trypsin    solution    for    local 
application,  168. 
fumigations,  antiseptic,  198. 

mercurial,  178. 
galvano-cautery,  159. 
general  principles  of,  151. 
hypodermic  injection  of  mer- 
curial salts,  178. 
hyposulphite  of   soda,   inter- 
nally, 183. 
indications  to  be  used  in  the, 

150. 
inhalations,  197. 
intubation,  265. 
inunctions,  mercurial,  177. 
iodoform,  locally,  186,  222. 
iodol,  locally,  187. 
iron,  chloride  of,  162,  196,  201, 

220. 
irrigation,  210,  218. 
jaborandi,  169 
lactic  acid,  locally,  164. 
lemon-juice,  locally,  199. 
lime-water,  locally,  164,  236. 
local  applications,  156. 
menthol,  locally,  199. 
mercury,  salts  of,  171,  173, 178, 

222. 
modes  of  employing  remedies, 

155. 
of     adenitis    in     diphtheria, 

■  231. 
of  constitutional  diphtheria, 

230. 
of  diphtheritic  paralysis,  254. 
of  heart-failure,  233. 
of  laryngeal  diphtheria,  235. 

299. 
of  nasal  diphtheria,  224. 


INDEX. 


325 


Treatment  of  pharyngeal    diph- 
theria, early  stage,  214. 
later  stage,  229. 
oil  ol  peppermint  locally,  199. 
oil  of  turpentine,  194. 
oxygen,  188. 
ozone  inhalation,  189. 
papayotin,  locally,  168,  237. 
pepsin,  locally,  166. 
permanganate  of  potassium, 

locally,  188. 
peroxide   of    hydrogen,    188, 

999 

pilocarpine,  169. 

prophylactic,  of  laryngeal 
diphtheria,  285. 

quinine,  204,  219,  233. 

resorcine,  182,  196. 

results  of,  153. 

salicylate  of  sodium,  218. 

salicylic  acid,  180,  220. 

special  indications  to  be  met 
in  the  case  of  children,  152. 

specifics,  208. 

sprays,  155,  215,  236,  238. 

steam  inhalations,  163,  239. 

sulphur,  182,  222. 

thymol,  local  use  of,  199. 

tracheotomy,  244. 

trypsin,  167,  237. 

turpentine,  194,  197,  222,  241. 

turpeth  mineral,  242. 

vapor,  163,  197,  238. 

veratrum  viride,  209. 

vinegar,  locally,  199. 
Trendelenberg,   26,  32,  58. 
Trideau,  cubebs  and  copaiba  in 

diphtheria,  208. 
Trousseau,  oedema  in  diphtheritic 
albuminuria,  92. 

on  the  advantages  of  early 
tracheotomy,  248. 

paralysis  beginning  in  the  ex- 
tremities after  cutaneous 
diphtheria,  116. 

term  diphtherie  suggested 
by,  1. 

unsuccessful  attempt  at  inoc- 
ulation by,  26. 

use  of  actual  cautery  by,  158. 

use  of  alum  and  tannin  by, 
161. 

views  concerning  the  prog- 
nostic significance  of  albu- 
minuria, 92. 

writings  on  diphtheria  by,  13. 
Trousseau's  tracheal  dilator,  251. 

tracheal  forceps,  253. 
Trypsin  as  a  solvent  of  false  mem- 
brane, 167. 

in  laryngeal  diphtheria,  237. 


Turpentine,  applicable  rather  to 
laryngeal  than  to   pharyn- 
geal diphtheria,  222. 
in  the  treatment  of  diphthe- 
ria, 194. 
inhalations,  197. 
vapor  in  laryngeal   diphthe- 
ria, 241. 
Turpeth    mineral     in     laryngeal 
diphtheria,  242. 

Urjemic  poisoning,  treatment  of, 

234. 
Urine,  albumin  in,  in  diphtheria, 

89. 

Vagina,  diphtheria  of,  88. 

Van  Wier,  4. 

Vapor,  warm,  use  of,  for  loosening 

the  false  membrane,  163. 
Vaporization,  advantages  of,  156. 
Vaporizing  atomizers,  238. 
Vapors,  antiseptic,  in  the  treat- 
ment of  diphtheria,  197. 
Velpeau,  158. 
Veratrum  viride  in  the  treatment 

of  diphtheria,  209. 
Villa  Real,  4. 
Vinegar,  local  use  of,  199. 
Virchow,    classification    of     false 
membranes,  48. 
forms  of  inflammation  of  mu- 
cous membranes    anatomi- 
cally distinguished  by,  14. 
views  of,  concerning  the  non- 
identity  of  diphtheria  and 
croup,  61. 
Vogelsang,  local  use  of  peroxide 

of  hydrogen,  188. 
Voice,  character  of,  in  croup,  290. 
in  diphtheritic  paralysis,  108, 

111. 
in  laryngeal  diphtheria,  82,  83. 
Vomiting    in    pharyngeal    diph- 
theria, 70. 
prognostic  significance  of,  142. 
Vulva,  diphtheria  of,  88. 

Wade,  W.  F.,  discovery  of  the 
occurrence  of  albuminuria  with 
diphtheria  by,  14. 
Wagner,  E.,  views  of,  concerning 
the  nature  of  false  membrane, 
46. 
Waxham,  F.  E.,  method  of  intu- 
bating, 275. 
relative  efficacy  of    different 
solvents  of  false  membrane, 
164. 
Weigert,  artificial  production  of 
false  membrane,  58. 


326 


INDEX. 


Weigert.  views  of.  concerning  the 
production  of  false  membrane, 
47. 
Werner,   P..   internal  use  of  bi- 
chloride of  mercury.  176. 
White,   W.    T..    examination    of 

author's  eases  by,  212. 
Winters,  J.  E..  abuse  of  mercuri- 
als in  the  treatment  of  diph- 
theria, 179. 
on  the  dose  of  chloride  of  iron, 
203. 
Wood   and   Formad,    account  of 
diphtheria    in    animals 
by,  23. 
artificial     production    of 

false  membrane,  58. 
conclusions    of.    concern- 
ing micro-organisms  in 
diphtheria,  32. 


Wood  and  Formad.  inoculation- 
experiments  by.  27,  30. 

Wounds,  diphtheria  of,  89. 

Wveth.  J.  A.,  on  tracheotome 
351. 


Ziegler,  location  of  the  pseudo- 
membrane,     in    secondary 
diphtheria,  107. 
mode  of   formation   of    false 
membrane,  49. 
v.  Ziemssen.    electrical  reactions 
in    diphtheritic     paralvsis. 
114. 
explanation  of  the  rarity  of 
oesophageal     inflammation, 
98. 
Zooglea.     in     diphtheritic   mem- 
brane, 32. 


1  2 


mm 


